HospitalInspections.org

Based on observation and interview, the facility failed to ensure care in a safe setting. The deficient practice is evidenced by the presence of 9 sleigh beds with head and foot boards that present ligature risks in the facility.
Findings:

Tour of the facility on 05/13/2025 between 2:15 PM and 2:20 PM revealed 9 of 20 beds in the facility were molded plastic sleigh style beds. The beds were noted to be in the rooms designated for the patients at suicide risk, beds a, b and e, as well as beds c, d, f, g, h, and i.

Review of the patient census at that time revealed no patients on suicide precautions.

At the time of discovery, S2DON verified the possibility of a ligature risk with the head and foot boards.

Based on record review and interview the governing body failed to ensure all provided services had established policies and procedures for safe provision of care and were included the Quality Assessment and Performance Improvement (QAPI) program . The deficient practice is evidenced by failure to establish policies for the transport of discharged patients and failure to include the transportation services in the QAPI plan.
Findings:

Review of the provided policy, HR-317 titled "Transportation," revealed in part, "Purpose: To clearly define the requirements and expectations of those employees for who transportation is an essential job function." Further review of the policy failed to reveal any guidelines related to transporting patients such as the documentation in a transport log or where stops could be made and the documentation of those stops.

Review of the QAPI measures for the year 2025 failed to reveal measures for the provision of transportation service.

In interview on 05/12/2025 at 10:19 AM, S1Adm verified transportation services was not included in the QAPI plan.

In interview on 05/12/2025 at 11:45 AM, S2DON explained the process of getting patients home after being released from the hospital. If the patient did not have family to pick the patient up and the patient had Medicaid, the discharge planner would arrange for transport with the Medicaid provider. If the patient was self pay and did not have family to pick them up, the transportation would be provided by the facility, by employees of the hospital or by the drivers of the outpatient clinic. S2DON also verified the policy on transportation referenced above did not contain any instructions to the drivers about keep a log of those transported or where stops could be made for gas and restrooms.

In interview on 05/12/2025 at 2:15 PM, S4SO verified that her job occasionally included the transporting of patients to their home after discharge. S4SO verified she was not aware of policies restricting where she could stop along the way and verified she was never instructed to wait outside the residence until the patient went inside when returning the patients to their place of residence.

Based on record review and interview, the facility failed to ensure the discharge plan was updated as needed. The deficient practice is evidenced by failure of the discharge planning staff to document changes made during the discharge planning process in 1 (#1) of 3 (#1-#3) reviewed records.
Findings:

Review of the medical record for Patient #1 revealed the patient was involuntarily admitted on 04/30/2025. At the time of admission, the patient was the resident of a group home, but refused release of information to the home. Further review of the record revealed the patient was discharge back to the same group home on 05/08/2025, but there was no documentation in the medical record of contact with the home to verify that they would accept Patient #1 back.

In interview on 05/12/2025 at 1:42PM, S2DON verified there was no documentation the group home was contacted during Patient #1's admission.

In interview on 05/12/2025 at 1:44 PM, S3DP verified she did not document any updates to the discharge plan, but verified she had worked on his discharge planning throughout his stay. S3DP verified the Patient #1 had informed her after admission that he had been accepted to another home in Baton Rouge. S3DP verified that she called the facility and the representatives of the facility had no knowledge of him. Patient #1 then agreed to return to his original group home. S3DP further explained that Patient #1 was discharged on 05/07/2025, but the weather was too bad to travel the distance to his group home, so the discharge was delayed a day. S3DP verified the group home was notified by phone of the delay of discharge and the home was also notified by phone on 05/08/2025 that he would be leaving the facility. S3DP verified she did not document in the medical record of Patient #1 her efforts related to discharge planning and verified the plan was never updated after the initial plan was established.