The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

JENNINGS AMERICAN LEGION HOSPITAL 1634 ELTON ROAD JENNINGS, LA 70546 Feb. 3, 2012
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, policy review, and clinical record review, the hospital failed to follow their policy of entering all patients who enter the hospital for medical treatment into the central booking log as evidenced by not posting patient #5's entrance into the hospital on 2 separate occasions. Findings:

On 2/2/12 at 2:45 p.m. in a face-to-face interview with S3 ED Director, he stated every person who enters the ED is placed in the central booking log. He also stated patients who enter the ED are triaged by a Registered Nurse. S3 confirmed that patient #5 was not triaged on either visit she made to the ED on 1/28/11 by the Registered Nurse; therefore, she was not placed in the central booking log.

Record review of the central booking log, for the month of December 2011, generated by S18 RN, Interdepartmental Technology (IT) Liaison, revealed patient #5 had two admissions to the hospital's ED. Patient #5 entered the ED on 12/26/11 at 11:15 a.m. with a diagnosis of Dystonic Reaction. Patient #5 was discharged on [DATE] at 13:38 (1:38 p.m.). Patient #5 entered the ED on 12/27/11 at 20:29 (8:29 p.m.) with a diagnosis of Substance Abuse and was discharged at 22:20 (10:20 p.m.). There was no evidence patient #5 was logged into the central booking log for the two visits she made to the ED on 12/28/12. There was no evidence in the central booking log for the dates of December 1-31, 2011, patient #5 had entered the ED on 2 visits on 12/28/11.

Record review of S3 ED Director's notes on ER returns for the month of December 2011 revealed Patient #5 had been admitted on [DATE] and was discharged . Then 19 hours later, she returned to the ED on 12/27/11 and was discharged the same night.

On 2/1/12 at 1:50 p.m., in a face-to-face interview with S3, he stated he keeps track of all the "significant returns" to the ED. He explained that a "significant return" indicates a patient is seen in ER and then returns to the ED within 72 hours. S2 confirmed patient #5's return to the ED on 12/28/11 on two separate occasions should have been logged into the central booking. He also explained since the patient had not been assessed, the patient's visits were not recorded into the central booking log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and policy review, the hospital failed to provide medical screening for 1 of 15 patients out of 20 clinical records reviewed as evidenced by no documented evidence patient #5 was given medical screening by either the nursing staff or physician on duty on 12/28/11 at 11:52 p.m. when the patient entered the hospital ED to receive emergency medical care. This resulted in an immediate jeopardy situation for patient #5 as evidenced by patient #5 leaving the ED in an incoherent state, running down the middle of the street in front of the hospital headed toward the interstate, being subdued and placed in handcuffs by local policemen, and then brought back to the ED a second time at 12:10 a.m. on 12/29/11. During the second entrance to the ED, patient #5 did not receive any screening examination to determine whether an emergency medical condition existed. Findings:

On 2/3/12 at 8:26 a.m. in a face-to-face interview with S2 Director of Nursing (DON), she stated she was informed of the incident the next morning by the S9 RN, Night Supervisor. S2 stated the ED was full at the time of the incident. She added the usual procedure if all the rooms are taken, then the staff will place the patient in a hall stretcher outside the emergency room s, but still in the emergency department. S2 stated if patients come in and are not a high level of acuity, then they are asked to go sit in the waiting area. S2 stated she did not know the acuity level of patient #5 when patient #5 arrived by EMS to the ED.

On 2/3/12 at 9:05 a.m. in a face-to-face interview with S6 RN, she confirmed patient #5 was brought to the ED by ambulance. She stated patient #5 was singing loudly and talking incoherently. S6 stated S4 ED Medical Director was on duty that night. S6 alleged S4 MD told her to take patient #5 to the waiting area because patient #5 was being disruptive. S6 stated EMS brought the patient to the waiting room still on the stretcher. The EMS personnel assisted patient #5 off the stretcher and into a chair in the waiting room. S6 stated she was trying to bring patient #5 to the triage room when patient #5 ran out the entrance door to the waiting room. S6 expressed concern because the patient ran across the street without looking. S6 stated in her professional opinion, patient #5 should not have been send to the waiting area because patient #5 was displaying signs of mental instability and could have been a danger to self. S6 confirmed the hospital's policy indicates confused patients who arrive by ambulance are to be triaged in the ED, not in the waiting area. S6 confirmed the hospital's policy was not followed for patient #5 during this first visit to the ED.

The incidence of events which took place according to S6 RN's statement was confirmed by S12 Security Guard, S7 RN, and S19 CNA/ER Technician.

On 2/3/12 at 9:45 a.m. in a face-to-face interview with S12 Security Guard, he stated he observed several cops catching patient #5 using police tactics (physically pushing patient #5 to the ground and handcuffing her.) By the time S12 returned to the ED, the police were in the ED with patient #5. S12 stated the police asked S4 MD what he wanted to do with patient #5. S12 stated he did not hear S4's response to the policemen.

On 2/3/12 at 10:17 a.m. in a face-to-face interview with S7 RN, he observed the police bringing patient #5, who was in handcuffs, back to the ED. He stated patient #5 was talking loudly and was trying to kick the policemen who were holding her arms. S7 does not recall the police asking the physician anything. S7 observed the policemen turn around with patient #5 and leave the ED. S7 confirmed, in his professional opinion, patient #5 was very combative, incoherent, and mentally unstable. S7 confirmed patient #5 needed a medical screening, but it was not done on patient #5 during this second visit. S7 confirmed the hospital did not follow the policy regarding triaging and assessing patients for patient #5.

On 2/3/12 at 10:34 a.m. in a face-to-face interview with S8 RN, she was not aware patient #5 had not been triaged. She was under the impression that S6 RN had completed the triage on patient #5 because patient #5 was sent to the waiting room to be triaged during the first visit. The second appearance of patient #5, S8 remembers patient #5 was very combative, talking loudly, and trying to kick policemen. S8 remembers S4 MD coming out of a patient's room and asked what was going on. S8 stated she did not remember the MD's answer. She observed the policemen leave the ED with patient #5 who was still handcuffed.

On 2/3/12 at 12:05 p.m. in a face-to-face interview, S4 MD stated when EMS brought patient #5 to the ED, she was singing loudly; yet, her vital signs were stable according to the EMT's report. He told the EMTs to bring the patient to the waiting area for triage. He believed the patient was physically stable. S4 MD stated he was surprised when he heard patient #5 had left the waiting area and was running down the street. He told the ED nurses to call the police. S4 stated that 1/2 hour to 1 hour later, the policemen brought patient #5 back to the ED, this time in handcuffs. S4 confirmed he was in another patient's room when he heard the commotion in the ED. S4 denied he told the policemen that patient #5 needed jail and not ED. He confirmed he did not know if she was having a medical or psychiatric emergency because he had not assessed her.

Record review of the policy titled "Triage and Assessment of Patients" revealed under Policy (pg 1 of 3): "Patients presenting to the Information Desk will be sent to Triage and vital signs with an assessment will be obtained by a nurse." Under Procedure (pg 1 of 3), #2 reads: "The ED nurse will assess and triage patient. The patient is then given a triage category of resuscitation (1), emergent (2), urgent (3), nonurgent (4), and referred (5). All 1's and 2's will immediately go to an emergency room ; registration will take place at the bedside or by a family member. The 3's, 4's, and 5's will be brought to an emergency room if available after triage; if a room is not available, the patient will be sent to register.
#3. If the patient arrives through the ambulance entrance and is a 3, 4, or 5, the patient is placed in an emergency room if bed available and an ED Nurse assesses them. If there are no ED beds available, the patient will be sent to triage for assessment, then to be registered. The patient will wait in the front waiting room until a room becomes available."

Triage Classification (pg 2 of 3) revealed Level II: Emergent- High risk; acute confusion, lethargy, or disorientation; distress or severe pain. Patient cannot wait." Psychiatric symptoms in this category included combative, hostile, hysterical, suicidal, homicidal, trauma with ETOH (alcohol intoxication).
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and policy review, the hospital failed to ensure the policy regarding triaging and assessment of patients was followed for 1 of 15 patients out of 20 clinical records reviewed, which resulted in an immediate jeopardy for patient #5 as evidenced by patient #5, who was confused and incoherent, leaving the Emergency Department (ED) waiting area and running out to a busy street towards the interstate. Patient #5 was sent to the waiting area without being assessed and triaged based on the Emergency Severity Index (ESI). Findings:

On 2/1/12 at 9:44 a.m. an observation was made of the ED entrance on the north side of the hospital. There was a large sign at the road indicating the hospital provides emergency services. At this time, a sign was observed posted above where patients sat in the waiting room. The sign indicated that all individuals will be screened, treated, and stabilized.

Patient #5 was brought to the back entrance of the ED on 12/28/11 by Emergency Medical Services(EMS) "a" at 23:52 (11:52 p.m.). According to the EMS's Medical Record for patient #5, EMT #5 and EMT #6 arrived at patient #5's residence. The Scene Evaluation read: "Pt was sitting on her sidewalk being held in closed arms by a male friend/family. Pt rocking back and forth. Police were on the scene. Male stated Pt should be held or she would run away. Pt. willingly moved onto EMS stretcher and Pt restraints were applied."

EMT #5's assessment of the present illness reads: "Onset: Unknown. Description: Pt was breathing rapidly as from strenuous exercise. Pt was unable to speak in full sentences due to inadequate breathing. When Pt breathing slowed, Pt became paranoid and agitated and accused EMS and police of already knowing what happened. Pt started rocking back and forth on the stretcher and speaking in sentence fragments."

Under Response to Treatment, EMT #5's additional narrative included: "Pt improved once oxygen was given. Upon arriving in hospital ER, Pt began to rock back and forth more frequently and began to sing loudly. Hospital requested Pt be sent to triage. EMS helped Pt into triage chair." EMS "a" then left the hospital.


On 2/2/12 at 2:45 p.m. in a face-to-face interview with S3 ED Director, he stated every person who enters the ED is placed in the critical log. He also stated that patients who enter the ED are triaged by a Registered Nurse. S3 confirmed that patient #5 was not triaged on either visit she made to the ED on 12/28/11 by the Registered Nurse; therefore, no medical record was started. S3 explained patients are logged into the central ER log once a medical record is started and this begins with the triaging.

Record review of the policy titled "Organization of Nursing Departments: Emergency Department" Effective Date 10/03/11 (pg 1 of 2) reads" "Each patient who presents to the Emergency Department is triaged by qualified and competent RN to determine the priority status for treatment based upon medical staff approved triage criteria. The nursing admission assessment (Triage) and/or the Emergency Department Physician (EDP) assessment is initiated within 15 minutes (except in extremely emergent situations where additional staff must be called out to assess patients waiting to be seen.)"

Record review of the policy titled "Triage and Assessment of Patients" revealed under Policy (pg 1 of 3): "Patients presenting to the Information Desk will be sent to Triage and vital signs with an assessment will be obtained by a nurse." Under Procedure (pg 1 of 3), #2 reads: "The ED nurse will assess and triage patient. The patient is then given a triage category of resuscitation (1), emergent (2), urgent (3), nonurgent (4), and referred (5). All 1's and 2's will immediately go to an emergency room ; registration will take place at the bedside or by a family member. The 3's, 4's, and 5's will be brought to an emergency room if available after triage; if a room is not available, the patient will be sent to register.
#3. If the patient arrives through the ambulance entrance and is a 3, 4, or 5, the patient is placed in an emergency room if bed available and an ED Nurse assesses them. If there are no ED beds available, the patient will be sent to triage for assessment, then to be registered. The patient will wait in the front waiting room until a room becomes available."

Triage Classification (pg 2 of 3) revealed Level II: Emergent- High risk; acute confusion, lethargy, or disorientation; distress or severe pain. Patient cannot wait." Psychiatric symptoms in this category included combative, hostile, hysterical, suicidal, homicidal, trauma with ETOH (alcohol intoxication).

The hospital failed to follow the policy of assessing and triaging patient #5 who arrived through the ambulance entrance, therefore, the hospital placed the patient's safety at risk by sending the patient to the waiting room where she left the hospital running incoherently down the highway towards the interstate.