HospitalInspections.org

Based on record review and interviews the hospital failed to assess processes of care by failing to:

1. Identify the Emergency Department was not following the hospital's Falls Prevention and Resource Policy for 1 out of 7 sampled patients (Patient #3).
2. Revise the Emergency Department Triage Policy to correlate with the current triage process in the Emergency Department. Findings:

1. Falls
Review of the Falls Prevention and Resource Policy for Ochsner Medical Center-North Shore, Policy number OMCNS.NPSG.0.0.24, revealed in part "I. Scope: This policy applies to Ochsner Medical Center-Northshore, its employees, medical staff, contractors, patients and visitors regardless of service location or category of patient ....Procedure: A. Initial Assessment/Screening and Interventions
1. When an adult is admitted to a bed at hospital, a registered nurse should first complete the Morse Fall Scale Risk Screening Tool as part of the patient's admission assessment. The nurse should then complete the Medication Classification Assessment Component of the Morse Fall Scale Risk Screening Tool .....
2. Fall Risk Assessment
A Falls Risk Assessment will be completed to determine if a patient is a risk for falls. The proper order for determining the patient's fall risk shall be:
a. Morse Scale Assessment:
1. Patient ' s who score greater than 25 on the Morse Scale are considered at risk for falls
2. Patients who score 0-24 are considered at no risk for falls .....
A. Fall Prevention Interventions
1 All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers, family and visitor of the fall potential. Realizing some states have implemented specific guidelines, such as color-coded bands, it is advised that facilities follow their state-specified directives, if applicable.
2. Minimally, all of the following measures will be implemented at all times:
a. A reference-colored armband placed on the wrist and no-slip/skid socks applied to serve as identifiers/preventative measures for the entire healthcare team.
b. Patients who are on strict bed rest do not need to wear the no-slip/skid socks.
c. A label stating " Fall Risk " placed on the patient ' s Kardex and on the spine of the patient ' s chart.
d. A sign identifying the patient is at risk for falls is placed outside the patient ' s doorframe and above the patient ' s bed.
e. Evaluate patient ' s hydration status, which research evidence has shown to be a factor in a patient ' s risk for falls .....
3. Post-Fall Management
a. Assess for injury (e.g. abrasion, contusion, laceration, fracture, head injury, bleeding).
b. Obtain radiologic studies and lab tests as indicated by physician or licensed independent practitioner.
c. Complete Post-Fall Assessment Form and return to immediate supervisor.
d. Obtain vital signs, a physical assessment and neuro checks after every fall according to the following sequence:
Every 15 minutes x 4; every 30 min x 2, every 1 hour x 4; then every 4 hours x 48 hours. If vital signs are critical or the patient is deteriorating, continue vital signs every 15 minutes and call the physician and the Rapid Response Team.
e. Notification of fall:
Physician (if not previously called)
Patient's emergency contact
f. Description of the fall episode to include:
Witnesses to fall if any
Position in which the patient was found
Assessment post-fall (changes in ROM (range of motion), neuro status, etc.
Interventions initiated
Persons notified
Follow up activities
g. Monitor patient as condition warrants, per policy
h. Report the fall to the charge nurse and at shift report
i. Complete an Incident/Occurrence Report
j. Modify the Interdisciplinary Plan of Care as patient ' s condition warrants."


1. The medical record of Patient #3 was reviewed. This review revealed that Patient #3 presented to Ochsner Medical Center- Northshore Emergency Department on 06/23/11 at 4:28 a.m. and was triaged by S29(ED Registered Nurse) on 06/23/11 at 4:30 a.m. The ED (Emergency Department) Triage Assessment documented the Mechanism of injury as a fall and "c/o (complaint of) bilat (bilateral) knee pain and abrasions-fell getting from w/c (wheelchair) to bed striking knees on floor. No other trama noted. "Review of initial vital signs revealed: BP (blood pressure) 140/81, pulse 66, resp (respirations) 22, temp (temperature) 97.1, and SpO2( spot pulse ox) on room air 97. Review of the fall risk documentation on the Triage Assessment revealed the patient was assessed at risk for falls and fall risk was initiated, and the side rails were elevated. Her past medical history documented on the Triage assessment revealed she had ESRD (End Stage Renal Disease), Gastroparesis, Diabetes Mellitus, Neuropathy, Osteoarthritis, HTN (Hypertension), Macular Degeneration, and MI (Myocardial Infarction). Her past surgical history revealed she had a PEG tube, Subdural hematoma evacuation, Right arm graft, hysterectomy, 3 C-sections, appendectomy, hysterectomy, and cholecystectomy. Her social history revealed she resided in a nursing home. On continued review of her triage assessment revealed her cognitive perceptual status was documented as she was alert and orientated to 3 (person, place and time), her behavior was anxious, and she had no LOC (lost of consciousness). Her neurological assessment stated she had normal speech and no blurred vision and she was able to move all extremities. Review of her Skin Assessment revealed her skin was WNL (within normal limits) warm, dry and the integrity was not intact. Under comments handwritten documentation revealed there were multiply wounds/scratches to her BUE (bilateral upper extremities) and to her lower extremities she had self inflicted from scratching. The anterior picture of the diagram of the person on the assessment revealed the patient ' s middle right and left arm were circled and the patient's right and left leg from the knee area to the patient's ankles. The assessment was signed by S30 (ED Registered Nurse) on 06/23/11 at 4:40 a.m. Review of the ED Nursing Record Nurse's Notes revealed at 4:30 a.m. the patient ' s was taken to Room 1 via EMS( Emergency Medical Services) Her vital signs were: B/P 140/81, Pulse 66, Resp 20, SpO2 was 97 and her pain level was a 10. "c/o pain to LE ' s (lower extremities) 10/10. Sitting up on side of stretcher. Requesting something for pain. Md (medical doctor) to see pt. (patient) Vistaril 50 mg (milligrams) and Ultram 50 mg po (by mouth) adm (administered) at 4:45 a.m. per Md's orders. The entry was signed by S30(ED Registered Nurse). Pt discharged back to Facility B. Representative at Facility B stated they would send someone over with a w/c to pick her up. Pt resting in bed siderails up. Plan of care explained to patient. "Further review of the ED Nursing Record Nurse's Notes revealed at 6:00 a.m., " Pt screamed out and was found on floor beside bed. Bedrails up- Pt awake with an active epitaxis and swelling noted to forehead- MD at patients side and patient placed onto stretcher and eval (evaluated) by Md. Pt stated she was ready to go and got out of bed. Neosynephrine and packing to nares bilaterally, suctioned oral airway and CT(computerized tomography) ordered. Patient remain awake and alert with no changed noted in mental status." The next entry timed 7:00 a.m. revealed, "CT report to Md for review ABC's intact nasal packing in place with no active bleeding noted pt resting comfortable on stretcher responsive to verbal stimuli-report to on coming shift who assumed further care of patient. "The entry was documented by S15 (ED Registered Nurse). Continued review of the ED Nursing Record Nurse's Notes revealed at 7:10 a.m. the patient's vital signs were 134/61, pulse 70, resp 18, and SpO2 was 98. "Blood running from L (left) nare upon removal of dressing. Exam per S28 (ED MD). 5.5 Rapid Rhino nasal packing to L nare. Pt tolerated well. Observing pt." The entry was signed by S31 (ED Registered Nurse). 7:30 a.m. nursing entry revealed vital signs of 161/72, pulse 72, resp 16, and SpO2 100. No pain. "Nasal bleeding controlled with packing. Lg (large) ecchymosis, edema to forehead and bridge of nose s/p (status post) fall at 0600. Pt awake, drowsy, oriented, cooperative, HOB (head of bed) elevated (arrow pointing up) breaths sounds clear. Abd (abdomen) soft with feeding tube clean with dry dsg (dressing). Several skin tears bilateral arms. R(right) upper arm palp (palpable) thrill AV (arterial venous) fistula for dialysis. Petechia to bilat LE, particularly feet. No edema, no blanching VSS (vital signs stable). The entry was signed by S31.The entry for 8:00 a.m. had documentation of vital signs of 153/70, pulse 70. Resp 18, SpO2 99, and no pain. The entry revealed, "Ice to forehead, nose, cooperative, dozing off and on. SR (side rails) up x 2. In view of nsg (nursing) station. To X-ray for nasal bone."The entry was signed by S31. Another entry was time 8:30 a.m., the vital signs were 156/61, pulse 69, resp 18, SpO2 99, and no pain. The entry continued, "Arouses easily. Open eyes to command, moves all extremities, palp (palpable) thrill R upper arm shunt BS clear Abd soft with peg. Ice pack on face. The entry was signed by S31. Another entry was timed 9:25 a.m. the patient vital signs were recorded as 149/74, pulse 72, resp 16, Spo2 100. The patient ' s pain was recorded as a 3. The entry continued, "Arouse easily c/o nasal discomfort. VSS. Orientated to person, place. Verbalized understanding of returning to Facility B. Facial edema, ecchoymosis(see photo) . Assisted out of bed to WC without probs(problem) 9:30 a.m. Returned to Facility B with order in stable cond. (condition) Awake, oriented, coop (cooperative) PERL (pupils equal and reactive)." The entry was signed per S31.

A face to face interview was conducted with S15(ED Registered Nurse) on 07/05/11 at 1:30 p.m. He stated he was the nurse assigned to Patient #3 when she fell in the ED. He went on to state on 06/23/11 Patient #3 was in the ED for evaluation after a fall in Facility B. Around 5:30 a.m. she was awaiting for her transportation back to Facility B, she was alert and awake at the time. She was in Room #1, which is close to the nurse's station and the door was open. The side rails were up, the bed was in its lowest position, and the call light was at the head of the bed. S5 (Medical Director of the ED) and S15 were sitting in the nurse's station at the computers. S15 stated he saw S5 get up quickly from his chair and he followed him. Patient #3 was then found lying on the floor by her bed. Before the fall she was not attempting to get out of bed at all. S5 assessed the patient and put her back on the bed. The patient had a swollen area to her forehead and nasal bleeding. Packing was placed in her nares, but there was no change in her mental status. A CT scan was ordered and no problems were found. The patient was only complaining that her glasses may have been broken. 7 a.m. was the end of S15's shift and he gave report to S31 (ED Registered Nurse).

A phone interview was conducted with S31 (ED Registered Nurse) on 07/06/11 at 10:30 a.m. She stated when she received report from S15(ED Registered Nurse) Patient #3 was arouseable, but drowsy and she was able to answer questions. When questioned on how it is determined in the ED if a patient was at risk for a fall, she stated it depends on why the patient was in the ED (the chief complaint), the patient's history and in what condition the patient arrived to ED. She also stated if a patient was assessed at high risk for falls, the patient would be placed in a room in view of the nurse's station. Patient #3 was placed in room 1, which was in view of the nurse's station. The bed would be placed in low position; the call bell would be in reach of the patient, the door to the patient's room would be left open, and the side rails would be raised on the bed. When questioned on how the other staff in the ED would know the patient was high risk for falls, she stated they tell the other staff members verbally. When questioned if it is policy in the ED to put armbands on the patient's that are high risk for falls, she stated no. She further stated she didn't recall Patient #3 having an armband on to identify her as high risk for falls. She also stated the ED physician had asked the hospitalist to admit the patient to the hospital, but the hospitalist did not want to admit the patient to the hospital so S31 discharge her back to Facility B. Patient #3's CT scan results were negative and all her lab values were good. The patient was awake and alert and was able to verbalize when S31 discharge her to Facility B.

A face to face interview was conducted with S5 (ED Medical Director) on 07/06/11 at 7:30 a.m. When questioned what the ED does for patients at high risk for falls, he stated the nurses put the patient in a room close to the nurses' station, the side rails are up on the bed, and the nurses verbally relay to the physicians if a patient is at risk for falls.

An interview was conducted with S4 (Director of ED) on 07/05/11 at 9:55 a.m.
When questioned about the Fall policy for ED, he stated they went by the hospital fall policy and the ED did not have a specific policy. He went on to state the ED did not use the Morse scale to assessed if a patient was at risk for a fall. The nurses use their nursing judgment, if the patient is known to fall, if the patient has limited mobility, if the patient is confused, and the patient's history, the nurses consider the patient high risk for falls. When reviewing Patient #3's ED record he stated the patient was in Room 1, which is in view of the nurses' station and if a patient was assessed as high risk as this patient, the door to the room would be left open, the side rails would be up, and the bed would be in low position. With review of Patient #3's medical record he could not find documentation that the door to Room 1 was left open and if the bed was in low position. When questioned if he would expect documentation that the door was left open and the bed was in low position, he stated yes. When question about the post fall care of the patient, he stated the nurses obviously didn't follow policy related to the frequency of the neurological checks, vital signs, and physical assessments. Review of the ED record revealed partial neurological checks performed approximately 6 times, vital signs performed approximately 5 times and no complete physical assessment performed per the nursing staff.

Another interview was conducted with S4 (Director of ED) on 07/05/11 at 2:05 p.m. He stated the nurses are suppose to put on a yellow armband on a patient if they are assessed as high risk for falls; with review of the ED record he revealed there was no documentation of a yellow armband being place on the patient. He also stated when the nurse admits a patient to the ED, that nurse orientates the patient to the call system; with review of the ED record he revealed there was no documentation that the nurse orientated the patient to the call light system.

An interview was conducted with S1 (Risk Manager) on 07/05/11 at 1 p.m. She stated she was notified by the house supervisor when the fall occurred and she spoke to the ED staff the morning of 06/23/11. She went on to state she pulled the hospital's fall policy and pulled a copy of the patient's chart. She discovered issues were not fully documented and the ED did not follow the hospital's fall policy and education of the staff was a problem.

An interview was conducted with S3 (Director of Quality) on 07/06/11 at 9:15 a.m. She stated there was no new policy that had been put in place for falls in the ED as of yet, they are in the process of working on the RCA (root cause analysis) related to the incident on 06/23/11. She also stated the current hospital policy for falls does not work in the ED.





2. Triage

Review of the Triage policy #OMC-NS:PC revealed in part "...4. Patients will be seen by the triage nurse in order or arrival, severity of complaints, and or/symptoms...
4. Patient will be seen by the triage nurse in order of arrival, severity of complaints, and/or symptoms...
4. The triage note documented by the triage nurse will include name, chief complaint, vital signs, pain assessment, and classification...
Policy: The established categories are as follows:
Emergent... Urgent... Non-Urgent..."

Review of the Triage Assessment form used currently by the Emergency Department (ED) revealed under the section labeled Triage Level 5 levels of triage: Level 1: Resuscitation, Level 2: Emergent, Level 3: Urgent, Level 4: Less Urgent, and Level 5: Non-Urgent.

An interview was conducted with S4Director of ED on 07/01/11 at 1:45 p.m. He stated he had been Director of the ED for 3 years and in the 3 years he had been director of the ED, they had been using the 5 tier triage system not the 3 level triage system as indicated by the Triage policy. He went on to state he did not know when the hospital initially went to the 5 level triage system.

An interview was conducted with S3Director of Quality on 07/06/11 at 9:15 a.m. She stated the current triage policy does not meet the current triage process used in the ED.

Based on record review and interview the hospital failed to:
1. Ensure a Registered Nurse evaluate (determine the significance or condition of usually by careful appraisal and study/ assessment) patient's response to medication for 1 of 7 sampled patients (#1).
2. Ensure a Registered Nurse followed the hospital's Fall Prevention and Resource Policy for 1 out of 7 sampled patients (#3). Findings
1. Patient #1 was admitted to Ochsner's Emergency Department on 9/30/2010 at 1515 (3:15 p.m.) with a chief complaint of (decreased) appetite, and (decreased) LOC (level of consciousness).
Review of Physician S5's notes for Patient #1 dated 9/30/2010 at 1500 (3:00 p.m.) revealed in part, "decreased responsiveness, chronic dementia but daughter reports (decreased) appetite and lethargy. Lethargic. Disoriented to time/place. Review of Physician's Orders and Medications Administered revealed Patient #1 was administered Narcan 2 milligrams at 1618 (4:18 p.m.). Further review of Patient #1's entire medical record revealed no documented evidence to indicate Patient #1's response to the Narcan. Patient #1 was transferred back to the Nursing Home at 1930 (7:30 p.m./4 hours and 5 minutes after arrival to the Emergency Department). Review of Patient #1's medical record revealed no documented evidence of a nursing assessment of Patient #1's level of consciousness after the administration of Narcan or prior to the patient being discharged.
Review of an "Overview" of the medication "Naloxone (Narcan)" presented by the Ochsner Medical Center Northshore's Pharmacist S19 revealed in part, "Naloxone is an opioid antagonist that appears to be devoid of agonist actions. It appears to exert its opioid antagonist effects by competing for the same receptor sites. Naloxone is indicated for the completed or partial reversal of opioid CNS (Central Nervous System) depression, including respiratory depression, induced by natural and synthetic opioids. . . Intravenous: Doses of 0/4 to 1.2 mg (milligrams) have been shown to reverse unconsciousness due to various opioids within 1 - 2 minutes. Onset of action is usually 2 minutes. . . Elimination Half Life: In one study, the half-life ranged from 30 to 81 minutes in adults. . . "
During a telephone interview on 6/30/2011 at 9:30 a.m., Registered Nurse S16 indicated he (S16) had provided care to Patient #1 on 9/30/2010. S16 indicated there was no indication on the Medical Record for Patient #1 to indicate what the patient's baseline level of consciousness at the Nursing Home (Facility B) had been prior to the patient's change in condition which precipitated the visit to the Emergency Department. S16 indicated he (S16) did not know Patient #1's level of consciousness prior to the patient's significant change in condition. S16 indicated Patient #1 was assessed by him on 9/30/2010 at 1520 (3:20 p.m.). S16 indicated as per his nursing notes, Patient #1 was Alert and Oriented, Age Appropriate, Cooperative, Pupils equal and reactive, Normal speech, and moving all extremities with no weakness (physician note at 3:00 p.m. [20 minutes before assessment by RN S16] indicated the patient (#1) was lethargic, eyes open slow, disorient to time and place). S16 indicated he (S16) had administered Narcan to patient #1 at 1618 (4:18 p.m.) on 9/30/2010. S16 confirmed that he (S16) had failed to document an assessment after the administration of Narcan to Patient #1 in regards to the Patient's response. S16 indicated he (S16) was unsure of the duration of the effects of Narcan. S16 indicated he (S16) would not be able to recall if Patient #1 ' s level of consciousness improved with the administration of Narcan. S16 indicated he (S16) should have documented Patient #1's response to Narcan in the patient's medical record.
Review of the hospital policy titled, "Assessment and Reassessment (Hospitalized Patients) #OHS.NURS.017 " presented by the hospital as current policy revealed in part, " Patients will be reassessed at the following times; 6. Response to intervention. Essential elements or reassessment include: Focused physical system review based on medical diagnosis, Mental status evaluation, Pain assessment. . . "







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2. Falls
Review of the Falls Prevention and Resource Policy for Ochsner Medical Center-North Shore, policy number OMCNS.NPSG.O.O.24 revealed in part, "I. Scope: This policy applies to Ochsner Medical Center-Northshore, its employees, medical staff, contractors, patients and visitors regardless of service location or category of patient ....Procedure: A. Initial Assessment/Screening and Interventions
1. When an adult is admitted to a bed at hospital, a registered nurse should first complete the Morse Fall Scale Risk Screening Tool as part of the patient's admission assessment. The nurse should then complete the Medication Classification Assessment Component of the Morse Fall Scale Risk Screening Tool .....
2. Fall Risk Assessment
A Falls Risk Assessment will be completed to determine if a patient is a risk for falls. The proper order for determining the patient's fall risk shall be:
a. Morse Scale Assessment:
1. Patient's who score greater than 25 on the Morse Scale are considered at risk for falls.
2. Patients who score 0-24 are considered at no risk for falls .....
A. Fall Prevention Interventions
1 All patients identified as at risk for falls should have interventions implemented to alert other healthcare workers, family and visitor of the fall potential. Realizing some states have implemented specific guidelines, such as color-coded bands, it is advised that facilities follow their state-specified directives, if applicable.
2. Minimally, all of the following measures will be implemented at all times:
a. A reference-colored armband placed on the wrist and no-slip/skid socks applied to serve as identifiers/preventative measures for the entire healthcare team.
b. Patients who are on strict bed rest do not need to wear the no-slip/skid socks.
c. A label stating " Fall Risk " placed on the patient ' s Kardex and on the spine of the patient ' s chart.
d. A sign identifying the patient is at risk for falls is placed outside the patient ' s doorframe and above the patient ' s bed.
e. Evaluate patient ' s hydration status, which research evidence has shown to be a factor in a patient ' s risk for falls .....
3. Post-Fall Management
a. Assess for injury (e.g. abrasion, contusion, laceration, fracture, head injury, bleeding).
b. Obtain radiologic studies and lab tests as indicated by physician or licensed independent practitioner.
c. Complete Post-Fall Assessment Form and return to immediate supervisor.
d. Obtain vital signs, a physical assessment and neuro checks after every fall according to the following sequence:
Every 15 minutes x 4; every 30 min x 2, every 1 hour x 4; then every 4 hours x 48 hours.
If vital signs are critical or the patient is deteriorating, continue vital signs every 15 minutes and call the physician and the Rapid Response Team.
e. Notification of fall:
Physician (if not previously called)
Patient ' s emergency contact
f. Description of the fall episode to include:
Witnesses to fall if any
Position in which the patient was found
Assessment post-fall (changes in ROM (range of motion), neuro status, etc.
Interventions initiated
Persons notified
Follow up activities
g. Monitor patient as condition warrants, per policy
h. Report the fall to the charge nurse and at shift report
i. Complete an Incident/Occurrence Report
j. Modify the Interdisciplinary Plan of Care as patient ' s condition warrants."


The medical record of Patient #3 was reviewed. This review revealed that Patient #3 presented to Ochsner Medical Center- Northshore Emergency Department on 06/23/11 at 4:28 a.m. and was triaged by S29(ED Registered Nurse) on 06/23/11 at 4:30 a.m. The ED (Emergency Department) Triage Assessment documented the Mechanism of injury as a fall and "c/o (complaint of) bilat (bilateral) knee pain and abrasions-fell getting from w/c (wheelchair) to bed striking knees on floor. No other trama noted." Review of initial vital signs revealed: BP (blood pressure) 140/81, pulse 66, resp (respirations) 22, temp (temperature) 97.1, and SpO2( spot pulse ox) on room air 97. Review of the fall risk documentation on the Triage Assessment revealed the patient was assessed at risk for falls and fall risk was initiated, and the side rails were elevated. Her past medical history documented on the Triage assessment revealed she had ESRD (End Stage Renal Disease), Gastroparesis, Diabetes Mellitus, Neuropathy, Osteoarthritis, HTN (Hypertension), Macular Degeneration, and MI (Myocardial Infarction). Her past surgical history revealed she had a PEG tube, Subdural hematoma evacuation, Right arm graft, hysterectomy, 3 C-sections, appendectomy, hysterectomy, and cholecytectomy. Her social history revealed she resided in a nursing home. On continued review of her triage assessment revealed her cognitive perceptual status was documented as she was alert and orientated to 3 (person, place and time), her behavior was anxious, and she had no LOC (lost of consciousness). Her neurological assessment stated she had normal speech and no blurred vision and she was able to move all extremities. Review of her Skin Assessment revealed her skin was WNL (within normal limits) warm, dry and the integrity was not intact. Under comments handwritten documentation revealed there were multiply wounds/scratches to her BUE (bilateral upper extremities) and to her lower extremities she had self inflicted from scratching. The anterior picture of the diagram of the person on the assessment revealed the patient ' s middle right and left arm were circled and the patient ' s right and left leg from the knee area to the patient ' s ankles. The assessment was signed by S30 (ED Registered Nurse) on 06/23/11 at 4:40 a.m. Review of the ED Nursing Record Nurse's Notes revealed at 4:30 a.m. the patient's was taken to Room 1 via EMS( Emergency Medical Services) Her vital signs were: B/P 140/81, Pulse 66, Resp 20, SpO2 was 97 and her pain level was a 10. "c/o pain to LE ' s (lower extremities) 10/10. Sitting up on side of stretcher. Requesting something for pain. Md (medical doctor) to see pt. (patient) Vistaril 50 mg (milligrams) and Ultram 50 mg po (by mouth) adm (administered) at 4:45 a.m. per Md ' s orders. The entry was signed by S30(ED Registered Nurse). Pt discharged back to Facility B. Representative at Facility B stated they would send someone over with a w/c to pick her up. Pt resting in bed siderails up. Plan of care explainted to patient. "Further review of the ED Nursing Record Nurse's Notes revealed at 6:00 a.m., "Pt screamed out and was found on floor beside bed. Bedrails up- Pt awake with an active epitaxis and swelling noted to forehead- MD at patients side and patient placed onto stretcher and eval (evaluated) by Md. Pt stated she was ready to go and got out of bed. Neosynephrine and packing to nares bilaterally, suctioned oral airway and CT(computerized tomography) ordered. Patient remain awake and alert with no changed noted in mental status. "The next entry timed 7:00 a.m. revealed, " CT report to Md for review ABC' s intact nasal packing in place with no active bleeding noted pt resting comfortable on stretcher responsive to verbal stimuli-report to on coming shift who assumed further care of patient." The entry was documented by S15 (ED Registered Nurse). Continued review of the ED Nursing Record Nurse's Notes revealed at 7:10 a.m. the patient's vital signs were 134/61, pulse 70, resp 18, and SpO2 was 98." Blood running from L (left) nare upon removal of dressing. Exam per S28 (ED MD). 5.5 Rapid Rhino nasal packing to L nare. Pt tolerated well. Observing pt." The entry was signed by S31 (ED Registered Nurse). 7:30 a.m. nursing entry revealed vital signs of 161/72, pulse 72, resp 16, and SpO2 100. No pain. "Nasal bleeding controlled with packing. Lg (large) ecchymosis, edema to forehead and bridge of nose s/p (status post) fall at 0600. Pt awake, drowsy, oriented, cooperative, HOB (head of bed) elevated (arrow pointing up) breaths sounds clear. Abd (abdomen) soft with feeding tube clean with dry dsg (dressing). Several skin tears bilateral arms. R(right) upper arm palp (palpable) thrill AV (arterial venous) fistula for dialysis. Petechai to bilat LE, particularly feet. No edema, no blanching VSS (vital signs stable). The entry was signed by S31.The entry for 8:00 a.m. had documentation of vital signs of 153/70, pulse 70. Resp 18, SpO2 99, and no pain. The entry revealed, " Ice to forehead, nose, cooperative, dozing off and on. SR (side rails) up x 2. In view of nsg (nursing) station. To xray for nasal bone. The entry was signed by S31. Another entry was time 8:30 a.m., the vital signs were 156/61, pulse 69, resp 18, SpO2 99, and no pain. The entry continued, "Arouses easily. Open eyes to command, moves all extremities, palp (palpable) thrill R upper arm shunt BS clear Abd soft with peg. Ice pack on face. The entry was signed by S31. Another entry was timed 9:25 a.m. the patient vital signs were recorded as 149/74, pulse 72, resp 16, Spo2 100. The patient ' s pain was recorded as a 3. The entry continued, " Arouse easily c/o nasal discomfort. VSS. Orientated to person, place. Verbalized understanding of returning to Facility B. Facial edema, ecchoymosis(see photo) . Assisted out of bed to WC without probs(problem) 9:30 a.m. Returned to Facility B with order in stable cond. (condition) Awake, oriented, coop (cooperative) PERL (pupils equal and reactive). " The entry was signed per S31.

A face to face interview was conducted with S15(ED Registered Nurse) on 07/05/11 at 1:30 p.m. He stated he was the nurse assigned to Patient #3 when she fell in the ED. He went on to state on 06/23/11 Patient #3 was in the ED for evaluation after a fall in Facility B. Around 5:30 a.m. she was awaiting for her transportation back to Facility B, she was alert and awake at the time. She was in Room #1, which is close to the nurse's station and the door was open. The side rails were up, the bed was in its lowest position, and the call light was at the head of the bed. S5 (Medical Director of the ED) and S15 were sitting in the nurse's station at the computers. S15 stated he saw S5 get up quickly from his chair and he followed him. Patient #3 was then found lying on the floor by her bed. Before the fall she was not attempting to get out of bed at all. S5 assessed the patient and put her back on the bed. The patient had a swollen area to her forehead and nasal bleeding. Packing was placed in her nares, but there was no change in her mental status. A CT scan was ordered and no problems were found. The patient was only complaining that her glasses may have been broken. 7 a.m. was the end of S15's shift and he gave report to S31 (ED Registered Nurse).

A phone interview was conducted with S31 (ED Registered Nurse) on 07/06/11 at 10:30 a.m. She stated when she received report from S15(ED Registered Nurse) Patient #3 was arouseable, but drowsy and she was able to answer questions. When questioned on how it is determined in the ED if a patient was at risk for a fall, she stated it depends on why the patient was in the ED (the chief complaint), the patient's history and in what condition the patient arrived to ED. She also stated if a patient was assessed at high risk for falls, the patient would be placed in a room in view of the nurse's station. Patient #3 was placed in room 1, which was in view of the nurse's station. The bed would be placed in low position; the call bell would be in reach of the patient, the door to the patient's room would be left open, and the side rails would be raised on the bed. When questioned on how the other staff in the ED would know the patient was high risk for falls, she stated they tell the other staff members verbally. When questioned if it is policy in the ED to put armbands on the patient's that are high risk for falls, she stated no. She further stated she didn't recall Patient #3 having an armband on to identify her as high risk for falls.

A face to face interview was conducted with S5 (ED Medical Director) on 07/06/11 at 7:30 a.m. When questioned what the ED does for patients at high risk for falls, he stated the nurses put the patient in a room close to the nurses' station, the side rails are up on the beds, and the nurses verbally relay to the physicians if a patient is at risk for falls.

An interview was conducted with S4 (Director of ED) on 07/05/11 at 9:55 a.m.
When questioned about the Fall policy for ED, he stated they went by the hospital fall policy and the ED did not have a specific policy. He went on to state the ED did not use the Morse scale to assessed if a patient was at risk for a fall. The nurses use their nursing judgment, if the patient is known to fall, if the patient has limited mobility, if the patient is confused, and the patient's history, they consider the patient high risk for falls. When reviewing Patient #3's ED record he stated the patient was in Room 1, which is in view of the nurses' station and if a patient was assessed as high risk as this patient was, the door to the room would be left open, the side rails would be up, and the bed would be in low position. With review of Patient #3's medical record he could not find documentation that the door to Room 1 was left open and if the bed was in low position. When questioned if he would expect documentation that the door was left open and the bed was in low position, he stated yes. When questioned about the post fall care of the patient, he stated the nurses obviously didn't follow policy related to the frequency of the neurological checks, vital signs, and physical assessments. Review of the ED record revealed partial neurological checks performed approximately 6 times, vital signs performed approximately 5 times and no complete physical assessment performed per the nursing staff.

Another interview was conducted with S4 (Director of ED) on 07/05/11 at 2:05 p.m. He stated the nurses are suppose to put on a yellow armband on a patient if they are assessed as high risk for falls; with review of the ED record he revealed there was no documentation of a yellow armband being place on the patient. He also stated when the nurse admits a patient to the ED, that nurse orientates the patient to the call system; with review of the ED record he revealed there was no documentation that the nurse orientated the patient to the call light system.

An interview was conducted with S1 (Risk Manager) on 07/05/11 at 1 p.m. She stated she was notified by the house supervisor when the fall occurred and she spoke to the ED staff the morning of 06/23/11. She went on to state she pulled the hospital 's fall policy and pulled a copy of the patient's chart. She discovered issues were not fully documented in the medical record and the ED did not follow the hospital's fall policy and education of the staff was a problem.

An interview was conducted with S3 (Director of Quality) on 07/06/11 at 9:15 a.m. She stated there was no new policy that had been put in place for falls in the ED as of yet, they are in the process of working on the RCA (root cause analysis) related to the incident on 06/23/11. She also stated the current hospital policy for falls does not work in the ED.

Based on record review and interview the hospital failed to ensure verbal orders were written according to hospital policy for 1 of 7 sampled patients (#1). Findings:
Review of Patient #1's Emergency Department Medical Record dated 9/29/2010 revealed a physician order for Clonidine 0.2 milligrams PO with no documented time of the order.
During a face to face interview on 6/30/2011 at 8:25 a.m., Registered Nurse S15 indicated he (S15) had provided care to Patient #1 on 9/29/2010. S15 indicated he (S15) had administered Clonidine 0.2 milligrams to Patient #1 at 2120 (9:20 p.m.) as per physician's verbal orders. S15 indicated Emergency Department Physician Orders for Clonidine were written by him (Registered Nurse S15) on the Physician's order sheet without any indication of the date and time of the order or any indication that the order had been a verbal order. S15 indicated it had been the practice in the Emergency Department for Nursing Staff to write verbal orders on the order sheet without documenting that the order was verbal. S15 indicated the Emergency Department Physician's signature was located at the bottom of the page where physician orders were documented; therefore, it had not been the practice in the Emergency Department for nursing staff to document that orders added to the page by nursing staff as verbal orders be documented as verbal orders.
During a face to face interview on 6/30/2011 at 9:00 a.m., Director of Nursing S2 indicated except during an emergency, all verbal orders should be written on Physician's order sheets as verbal orders to include the date and time the order was received and that the order had been read back and verified. S2 indicated all verbal orders should be signed by the physician.
Review of the hospital policy titled, " Physician Telephone and Verbal Orders-Read Back " presented by the hospital as their current policy revealed in part, " When phone and verbal orders are unavoidable, qualified personnel taking the order will write down the order first. The order is then read back verbatim to the practitioner who initiated the order. The practitioner should then verbally confirm that the order is correct. This process applies to all telephone and verbal orders, not just phone and verbal orders for medications. Verbal and telephone orders are entered into the medical record indicating the method (telephone or verbal, the physician the licensed professional obtaining the order. . . Physician must sign all verbal and telephone orders within 48 hours. . . "

Based on record review and interview, the hospital's Infection Control Officer failed to ensure the effective implementation of a system for investigating and/or controlling infections by failing to ensure hospital physicians had annual Tuberculosis (TB) screening and/or documented evidence that these screenings were in compliance with the CDC (Centers for Disease Control) guidelines as evidenced by 2 of 3 physician credentialing files having no evidence of TB screening within the past year (S5MD and S28MD) Findings:

Review of a CDC (Center for Disease Control) Recommendation and Report , 54(RR17); 1-141, document dated December 30, 2005 titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" revealed the following: "HCW's (Health Care Workers) who Should Be Included in a TB Surveillance Program." "HCW's refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCW's should be included in TB screening programs. All HCW's who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCW's who should be included in a TB screening program: Administrators or Managers, Bronchoscopy staff, Chaplains, Clerical staff, computer programmers, construction staff, Correctional officers, Craft or repair staff, Dental staff, Dietician or dietary staff, ED staff, Engineers, Food Service staff, Health aides, health and safety staff, housekeeping or custodial staff, Infection Control staff, ICU staff, Janitorial staff, Laboratory staff, Maintenance staff, Morgue staff, Nurses, Pathology laboratory staff, Patient transport staff (including EMS), Pediatric staff, Pharmacists, Phlebotomists, Physical and Occupational Therapists, Physicians (assistant, attending, fellow, resident, or intern), including Anesthesiologists, Pathologists, Psychiatrists, and Psychologists, Radiology staff, Respiratory Therapists, Social workers, Students (e.g., medical, nursing, technicians, and allied health), Technicians (e.g., health, laboratory, radiology, and animal), and Volunteers."
Review of Medical Staff Policy and Procedure for Immunization of Physicians and other Licensed Practitioners to Prevent Transmission of Infectious Diseases revealed, "The Medical Staff leaders encourage all members of the medical staff to adhere to Centers of Disease Control and Prevention's recommendations for immunizations."

Review of the credentialing records for S5 (ED Medical Director) revealed his initial appointment was in 2000. There was no documentation of a tuberculosis screening since his initial appointment. S25RN delivered the results for a TB Gold order inquiry that was drawn on S5MD. Review of the TB Gold order inquiry revealed that S5 had the lab drawn on 07/06/11 at 8:17 a.m. (the date the physician's TB results were requested).

Review of the Credentialing records for S28MD revealed his last reappointment was in April 2010. There was no documentation of a tuberculosis screen in his credentialing records.

An interview was conducted with S20 (VPMA) on 07/06/11 at 11:20 a.m. He stated there was no documentation of TB screening for S5 or S28. He stated TB screening was suppose to be done with credentialing every 2 years.

Based on record review and interview the hospital failed to ensure a patient's discharge plan was reassessed for appropriateness as evidenced by discharging a patient in an unstable condition for 1 of 7 sampled patients (Patient #1). Findings:
Patient #1 was admitted to Nursing Home, Facility B on 8/13/2010 post fractured femur.
Review of Patient #1's Nursing Documentation at Facility B (Nursing Home) revealed in part, " (Date 9/27/2010) 9:00 a.m., Resident in W/C (wheelchair) just finishing eating breakfast with set up per staff. . . 9/29/2010 9:00 a.m. - Resident sitting up in W/C at nurses station, just finished eating breakfast in dining room with set up per staff. . . Propels self slowly around facility. . . 5:00 p.m. - Resident left with transport via stretcher in ambulance to Ochsner (Medical Center) Hospital for changed mental status. Noted patient was unable to state her name and was very disoriented. . . 9:45 p.m. resident returns to unit via ambulance in stretcher with transport. Calm. . . 9/30/10 - 3:00 p.m. - Resident sent out because she had decreased LOC (level of consciousness), left via ambulance to Ochsner. . . "
Medical Records at Ochsner Medical Center Northshore for Patient #1 ' s Emergency Department visits on 9/29/2011, and 9/30/2011 were reviewed.
Patient #1 was admitted to Ochsner Medical Center's Emergency Department on 9/29/2011 at 1724 (5:24 p.m.) with a triage level of 3 (Urgent). Patient #1's chief complaint was documented as " ALOC (altered level of consciousness) " . Accucheck at triage was documented as 117 (no documented time). Nursing evaluation dated 9/29/2010 with no documented time revealed in part, PERRL (Pupils equal reactive to light/checked yes), Speech. Slow (with) response. GSC (Glasgow Coma Scale) of 13 out of a total possible score of 15. Further review of Nursing Notes dated 9/29/2010 at 1715 (5:15 p.m.) revealed in part, " Unable to assess at this time. Pt (Patient) not following commands. " Patient #1 had a Complete Blood Count, Basic Metabolic Profile, Catheterized Urinalysis, and Chest Xray. Patient #1 was administered Rocephin 1Gram IM (intramuscular) at 2022 (8:22 p.m.) and Clonidine 0.2 milligrams by mouth at 2120 (9:20 p.m.). Review of Physician's notes revealed in part, " Staff (at) Rehab reports that she is less responsive today. Seen by me 2 days ago for (left) knee pain/swelling. Appears same. Appears 0 (no) distress. " Urinalysis collected on 9/29/2010 at 1815 (6:15 p.m.) revealed color yellow, appearance hazy, Specific gravity 1.020 (normal less than or equal to 1.025), PH 5.0 (normal 6.0 - 8/0), leuk est 1+ (normal negative), nitrite positive (normal negative). Urine Culture results dated 9/29/2010 at 1815 (6:15 p.m.) revealed a positive culture for Escherichia Coli. Patient #1 was discharged back to Facility B (Nursing Home) on 9/29/2010 at 2133 (9:33 p.m.) with a Clinical Impression of Urinary Tract Infection and orders for Bactrim DS i po bid (one by mouth two times per day).
Patient #1 was admitted to Ochsner's Emergency Department on 9/30/2010 at 1515 (3:15 p.m.). Patient #1 was triaged a Level 3 (Urgent) with a chief complaint of (decreased) appetite, and (decreased) LOC (level of consciousness). Review of Physician S5's notes for Patient #1 dated 9/30/2010 at 1500 (3:00 p.m.) revealed in part, " decreased responsiveness, chronic dementia but daughter reports (decreased) appetite and lethargy. Lethargic. Disoriented to time/place. " A CT scan was ordered of Patient #1's head. Review of the Radiology report for Patient #1's CT dictated 9/30/2010 at 6:04 p.m. as a " stat dictation" revealed in part, "Clinical History: Altered level of consciousness. Impression: 1 cm (centimeter) probable lacunar infarct, ischemic injury of the left thalamus without hemorrhage or mass effect. Moderate enlargement of the ventricles consistent with centralized brain atrophy unchanged from 12 October 1994. Review of Patient #1's Physician Progress notes per Physician S5 revealed in part, "Discussed (with) (Physician S9/Primary Care Physician at Nursing Home) at 1800 (6:00 p.m.). Rec (recommend) return to NH (Nursing Home) and consult neurology as an outpatient. Will empirically tx (treat) c (with) Prilosec for possible gastritis. "Patient #1 was transferred back to the Nursing Home at 1930 (7:30 p.m./4 hours and 5 minutes after arrival to the Emergency Department). Review of Patient #1's medical record revealed no documented evidence of a nursing assessment of Patient #1's level of consciousness at the time of discharge.
Further review of Patient #1's Nursing Documentation at Facility B Nursing Home revealed in part, "9/30/10 - 8:00 p.m. Resident came back from Ochsner and appeared to be in critical condition. Put on O2 (oxygen) at 2LPM (liters per minute), O2 sat (saturations) 95%, telephoned (physician), she (Physician S9) ordered D51/2NS (Intravenous fluid) at 100 cc . . . She (Patient #1) appeared to have SOB (shortness of breath), so received orders to send out to (Facility A)."
Review of Patient #1's medical record from Facility A (Hospital) revealed the 79 year old female was admitted through the Emergency Department on 9/30/2010 at 2253 (10:53 p.m.). Physical exam of Patient #1 at 2340 (11:40 p.m.) revealed in part, "alert, non-verbal, breath sounds normal, CVS (Cardiovascular Status) reg. (regular) rate & rhythm. "Further review of Emergency Nursing Notes revealed Patient #1's vital signs at 2336 (11:36 p.m.) to indicate B/P (blood pressure) 146/85, Pulse 85, Respirations 18, SPO2 (Oxygen Saturation) 99%, GCS (Glasgow Coma Scale 11) M-5 (Motor localizes painful stimuli, attempts to remove offending stimulus), V-4 (Verbal Confused/Disoriented) , E-2 (Eyes- Opens eyes in response to painful stimuli). "Facility A Nursing Notes; timed 2330 (11:30 p.m.) (no documented date), revealed in part, " Pt (patient) to room. . . via stretcher. Alert. Pt does not respond verbally. Family states pt. normally speaks and converses. Pt. has been seen at (Facility A) today. Pt. from (Facility B Nursing Home). Diagnosed (with) UTI (Urinary Tract Infection). . . . "Patient #1 was admitted to the hospital (Facility B) on 10/01/2011 at 1254 (12:54 a.m.) with preliminary diagnoses that included Altered Mental Status (Change), UTI, Dementia, and R/O (rule out) CVA (Cerebral Vascular Accident). Review of Patient #1's History and Physical dictated 10/01/2011 at 1:13 p.m. revealed in part, "This 79 year old female . . . presented to the emergency room accompanied by her daughter, who said the patient has had altered mental status for approximately 2 days. She was seen at (Facility A) yesterday and was diagnosed with a urinary tract infection; a workup was performed there, including a CT scan, and we are awaiting that information. The patient's daughter said she (Patient 31) developed some slurred speech yesterday and has become less communicative. The daughter has also noticed a change in appetite over the past 2 days. . . General. . . She opens her eyes but does not follow commands. . . Review of Patient #1's Discharge Summary dictated 10/04/2010 at 9:33 a.m. revealed in part, " . . . admitted to the hospital with diagnosis of change in mental status. She has had computerized axial tomography scan of the brain which showed a lacunar infarct performed on September 30, 2010 at (Facility A). She was also diagnosed with a urinary tract infection. She arrived with organic brain syndrome. Her overall level of consciousness has improved. She answers yes or no although she is still demented. . . . Impression: Altered Mental Status, Cerebrovascular Accident, and stable for discharged back to skilled nursing center. Urinary tract Infection improving. "
Face to face interviews were conducted with Nursing Home Administrator S11 (Facility B), Licensed Practical Nurse (LPN) S12 (Facility B), Registered Nurse (RN) S13 (Facility B), and LPN S14 (Facility B) on 6/28/2011 at 2:00 p.m. S14 indicated Patient #1 had been sent to Ochsner Medical Center Northshore on three occasions, 9/27/2010, 9/29/2010, and 9/30/2010. S14 indicated initially on 9/27/2011 Patient #1 had been sent out due to leg pain. S14 indicated Patient #1 had been able to feed herself, propel herself in her wheelchair, and recognize staff and family. S14 indicated Patient #1 was demented in the form of being forgetful. S14 indicated Patient #1 was able to engage appropriately in conversations. S14 indicated on the date of 9/29/2010 Patient #1 had a significant change in her level of consciousness. S14 indicated Patient #1 was no longer able to feed herself or make conversations. S14 indicated Patient #1 no longer knew her own name. S14 indicated the staff were surprised that Patient #1 returned to the Nursing Home on 9/29/2010 given her significant alteration in level of consciousness. S14 indicated Patient #1 was sent back to Ochsner Medical Center on 9/30/2010 (3rd visit in four days) and again they (Ochsner Medical Center) discharged her back to the nursing home (Facility B). S14 indicated Patient #1 was transferred to Facility A (Hospital) when she returned to the Nursing Home from Ochsner Medical Center on 9/30/2010 due to an ongoing significant change in condition/level of consciousness. S14 indicated Facility A (Hospital) admitted Patient #1 with a stroke.
During a telephone interview on 6/29/2011 at 1450 (2:50 p.m.), LPN S8 indicated that she (S8) did not recall the specific details regarding Patient #1 on the date of 9/30/2010; however, she (S8) remembered that Patient #1 was not herself. S8 indicated Patient #1 was not communicating and was lethargic. S8 indicated Patient #1 had been transferred to Ochsner Medical Center Northshore due to an altered level of consciousness. S8 indicated Ochsner Medical Center sent Patient #1 back to the Nursing Home after evaluating her for an altered Level of Consciousness on 9/30/2011. S8 indicated she (S8) did not recall the specific details of Patient #1 ' s condition when she (S8) documented " Resident came back from Ochsner and appeared to be in critical condition. . . She appeared to have SOB (shortness of breath), so received orders to send out to (Facility A). " ; however, she (S8) knew the patient (#1) had no improvement, was not her normal self, and was very sick. S8 indicated Patient #1 was transferred to a different hospital (Facility A) as per physician's instructions. S8 indicated Facility A (Hospital) admitted Patient #1.
During a face to face interview on 6/30/2011 at 7:30 a.m., Physician S9 (Patient #1's Primary Care Physician at Facility B/Nursing Home) indicated she (S9) could not recall the specific events regarding Patient #1's medical issues in September of 2010; however, she (S9) had noticed a pattern with the treatment and release of patients that had been transferred from Facility B (Nursing Home) to Ochsner Medical Center's Emergency Department for evaluation of acute illnesses/injuries. Physician S9 indicated she (S9) frequently sent patients to Ochsner Medical Center Emergency Department and then had to re-send them upon return to Facility B for failure of Ochsner Medical Center ' s Emergency Department to stabilize/treat the patient. S9 indicated that although she (S9) did not recall the specific details of Patient #1 ' s medical issues in September 2010, she (S9) would think that any patient with a CT scan that indicated a thalamic lacunar infarct that also had acute changes in their level of consciousness would need to be admitted to the hospital for observation.
During a face to face interview on 6/29/2011 at 1350 (1:50 p.m.), Registered Nurse S10 indicated he (S10) provided care to Patient #1 on 9/29/2010. S10 indicated he (S10) did not remember the patient. S10 reviewed Patient #1's medical record. S10 indicated Patient #1 was confused, with an orientation of 1 - 2, which most likely meant the patient (#1) was alert to person and place only. S10 indicated Patient #1 had unequal pupils and was slow to respond with her speech. S10 indicated Patient #1 was not able to follow commands and therefore he (S10) was not able to do a complete neurological assessment. S10 indicated he (S10) did not know what Patient #1's Baseline Level of Consciousness was. S10 indicated he (S10) knew there had been a decrease in the Level of Consciousness (chief complaint from nursing home).
During a telephone interview on 6/30/2011 at 9:30 a.m., Registered Nurse S16 indicated he (S16) had provided care to Patient #1 on 9/30/2010. S16 indicated he (S16) did not know which nurse had taken report from the Nursing Home (Facility B) prior to the patient ' s arrival. S16 indicated there was no indication on the Medical Record for Patient #1 to indicate what the patient ' s baseline level of consciousness at the Nursing Home (Facility B) had been prior to the patient ' s change in condition which precipitated the visit to the Emergency Department. S16 indicated he (S16) did not know Patient #1's level of consciousness prior to the patient's significant change in condition.
During a telephone interview on 6/30/2011 at 1420 (2:20 p.m.), Hospitalist S18 indicated he (S18) was involved in the admission and treatment of Patient #1 at Facility A on 10/01/2010 Admission (pt. presented to Emergency Department at Facility A on 9/30/2010 and was held until admitted to the hospital on 10/01/2010). S18 indicated that anytime a patient presented to the hospital with acute changes in their level of consciousness associated with an abnormal CT scan, the hospital would be obligated to admit the patient for observations. S18 indicated Patient #1 had symptoms of slurred speech followed by inability to communicate as reported by the patient ' s daughter. S18 indicated this change in Patient #1's level of consciousness along with a CT scan indicating Thalmic Lacunar infarct indicated Patient #1 needed to be admitted to the hospital for observation.
During a telephone interview on 7/01/2011 at 11:05 a.m., Physician S5 indicated he was the Emergency Department Physician that treated Patient #1 on 9/29/2010 and 9/30/2010. Physician S5 indicated he (S5) could not remember the patient (#1) but had reviewed the Patient's Medical Record. S5 indicated he (S5) had interpreted the Radiologist Impression of the CT scan to mean there had been no changes in the Scan from the former CT scan performed in October 1994; however, after reading it today (7/01/2011) could see that it was not clear (Impression: 1 cm (centimeter) probable lacunar infarct, ischemic injury of the left thalamus without hemorrhage or mass effect. Moderate enlargement of the ventricles consistent with centralized brain atrophy unchanged from 12 October 1994.) as to whether the lacunar infarct was old or new. S5 indicated that he (S5) documented a discussion with Physician S9 on the Medical Record although he (S5) could not recall the specifics of the discussion. Physician S5 indicated Physician S9 would have known more of the patient's (#1) ongoing condition since she (S9) was the patient's (#1) Primary Care Physician at the Nursing Home. S5 further indicated he (S5) probably would have admitted Patient #1 into the hospital for observation if he (S5) had known the patient (#1) had been able to carry on conversations, feed herself, and propel herself in a wheelchair prior to the sudden change in her Level of Consciousness at the Nursing Home.
During a face to face interview on 6/29/2011 at 12:50 p.m., Radiologists S6 indicated the CT scan reading done on Patient #1's Head on 9/30/2010 indicated the patient had a possible small stroke with an ischemic injury of the left thalamus but no hemorrhage. S6 indicated the function of the Radiologist was to read/interpret the CT scan. S6 indicated it would be the admitting physician that determined how the patient would be treated based on the reading.
During a face to face interview on 7/01/2011 at 11:30 a.m.,Vice President of Medical Affairs at Ochsner Medical Center Northshore, Physician S20 indicated, after reviewing the medical record of Patient #1, that he (S20) interpreted the Radiologist Report to indicate the patient's enlargement of ventricles consistent with centralized brain atrophy to be unchanged from October 12, 1994. S20 indicated the Impression of 1 centimeter probable lacunar infarct, ischemic jury of the left thalamus appeared to be a new finding. S20 further indicated that he (S20) would have admitted Patient #1 into the hospital had he (S20) been the treating physician on 9/30/2010 due to recent history of an acute change in the patient's level of consciousness and given the CT scan results.