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.

LAKE CHARLES MEMORIAL HOSPITAL 1701 OAK PARK BLVD LAKE CHARLES, LA 70601 Jan. 30, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) failing to ensure patients were triaged in a timely manner after presentation to the emergency room in order to assure patients at risk to themselves or others were identified and assigned the appropriate acuity level as per hospital's policy for 13 (#3 (2 visits on 01/05/13 at 1:46 a.m. and on 01/05/13 at 3:46 p.m.), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A0144)

2) failing to ensure hospital's policy of 1:1 supervision was put into place and maintained for patients with a chief complaint or assessment findings of danger to self or others for 13 (#3 (2 visits on 12/09/12 and on 12/10/12), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A0144)

3) failing to ensure patients that presented to the emergency room considered to be a risk to themselves or others were assessed by an emergency room physician as per hospital policy for 11 (#7, #8, #9, #11, #12, #13, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 -#R24). (see findings at A0144)

4) failing to ensure patients considered to be a risk to themselves or others had a Mental Health Assessment after presentation to the emergency room performed as per hospital policy for 11 (#7's visit on 12/28/12, #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A0144)
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record reviews and interviews the hospital failed to ensure that patients received care in a safe setting as evidenced by:

1) failing to ensure patients were triaged in a timely manner after presentation to the emergency room in order to assure patients at risk to themselves or others were identified as per hospital policy for 13 (#3 (2 visits on 01/05/13 1:46 a.m. and on 01/05/13 3:46 p.m.), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

2) failing to ensure hospital policy of 1:1 supervision was put into place and maintained for patients with a chief complaint or assessment findings of danger to self or others for 13 (#3 (2 visits on 12/09/12 and on 12/10/12), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

3) failing to ensure patients that presented to the emergency room considered to be a risk to themselves or others were assessed by an emergency room physician as per hospital policy for 10 (#7 (visit on 12/28/12), #8, #9, #11, #12, #13, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 -#R24).

4) failing to ensure that patients considered to be a risk to themselves or others had a Mental Health Assessment after presentation to the emergency room performed as per policy for 11 (#7 (visit on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

Findings:

1)

Patient #3

Review of ambulance run reports for 01/05/13 from ambulance service "a" revealed that patient #3 was transported twice to Lake Charles Memorial Hospital (LCMH) on 01/05/13 and once to hospital "a" on 01/05/13. Review of the LCMH ER Central Log revealed the hospital has no documentation of either arrival of patient #3 on 01/05/13.

FIRST VISIT OF PATIENT #3 ON 01/05/13 AT 1:46 a.m.

Review of the first ambulance run report revealed in part: "Incident 911. Date: 01/05/2013. Patient: (patient #3). Complaint: Behavioral...Patient found: pt was sitting in a carport talking to pd (police department) and was in just his underwear...History of Present Illness...Description: pt was sleeping in his mother shed and had been for days pt had stop taking his meds pt was in just his underwear sitting outside...Past Medical History: psychiatric, bipolar...Observation and Exam. Secondary Conditions for Ambulance Transport: Hallucinations, Paranoia...Dispatch Time: Clock Start 01:30 (1:30 a.m.)...Arrive at Hospital: 01:46 (1:46 a.m.)."

Review of a statement from ambulance service "a" crew member S19 revealed the following: "...Incident # 911. (ambulance service "a") Crew: S18/S19 (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2012, my partner and I transported patient (#3) to the Lake Charles Memorial ER from his residence in Lake Charles. We arrived at the hospital with the patient at 1:46 a.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, I was instructed by an ER staff nurse that the patient was being triaged and that I should bring him to the ER lobby. My partner and I brought him to the ER lobby, had him sit in a chair, I gave his demographic information to the ER admit clerk, and my partner and I departed the hospital. Respectfully, (S19)..."

Review of a statement from S15 revealed the following: "Incident # 911. (ambulance service "a") Crew: (S18)/(S19) (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, Unit 402 transported (patient #3) from his residence to the Lake Charles Memorial Hospital ER. CAD (Computer Aided Dispatch) tracking by GPS (global positioning satellite) shows that they arrived at LCMH at 01:46:34 (1:46 a.m.). Respectfully, (S15)..."

In an interview on 01/23/13 at 2:00 p.m. with S1CNO she was shown a copy of the ambulance run report indicating patient #3 was brought to LCMH ER at 1:46 a.m. on 01/05/13. S1CNO stated she "would have to look into it."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13 for his 1:46 a.m. arrival via ambulance.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record (registration, triage, assessment, interventions, medical screening exam, treatment, discharge) of patient #3 being at the ER for this ambulance arrival on 01/05/13 at 1:46 a.m.

SECOND VISIT OF PATIENT #3 ON 01/05/13 AT 3:46 p.m.

Review of the second run report revealed in part: "Incident 092. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 2XXX Anita Dr., Lake Charles, LA...Destination: LCMH...Patient Found: PT found outside talking to police...History of Present Illness...Description: Police called (ambulance service "a") for a psych pt that needed to be evaluated. Police state the pt was walking around a neighborhood pointing at people and saying bizarre things. Pt states he takes psych meds but he ran out. Pt also states he smoked some marijuana...Past Medical History...Psychiatric...Observation and Exam...Secondary Conditions for Ambulance Transport: Unmanageable behavior, Restraints; to prevent harm to self/others, hallucinations...(no vital signs documented)...Response to Treatment...Additional Narrative: During transport to the hospital the pt would talk to himself and say bizarre things and laugh. Pt refused vitals and pt refused to talk to me. Once we arrived at the ED we brought the pt inside and was assigned a psych room. Enroute to the psych room the pt would constantly say bizarre things and at one point he took his shoes off and threw them at a doctor. Once we put the pt in the psych room a nurse came in and said he was "banned" from this hospital and that he could not be seen here. Police were called to ED and the pt was escorted out of the ED. We then had to transport the pt to (hospital "a") (Inc # 190). Dispatch Time: Clock Start 15:26 (3:26 p.m.)...Arrive at hospital 15:46 (3:46 p.m.)."

Review of the third run report revealed in part: "Incident 192. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 1XXX Oak Park Blvd., Lake Charles, LA (LCMH)...Destination: (hospital "a")...Patient Found: ambulatory at scene...History of Present Illness...Description: 33 y/o male being transported to (hospital "a") for a psych evaluation. (PD1) requested the patient be "checked out" due to bizarre behavior and the pt stated he was out of his meds...Past Medical History...Psychiatric, bipolar, schizophrenia...Observation and Exam...Secondary Conditions for Ambulance Transport: hallucinations...Response to Treatment...Additional Narrative: Pt was unwilling to sign sig (signature) page. Pt was initially transported to Lake Charles Memorial Hospital for treatment
but they refused to evaluate the patient. They requested the patient be escorted off the property by (PD1). Transportation to (hospital "a") was without incident. Transfer of care to (hospital "a") was without incident. Dispatch Time: Clock Start 16:19 (4:19 p.m.)...Arrive at hospital 16:26 (4:26 p.m.)."

Review of a statement from S16 (ambulance service "a") revealed the following: "...Incident # 092. (ambulance service "a") Crew: (S16/S17) (Unit 403). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, my partner and I transported patient (Patient #3) to the Lake Charles Memorial Hospital ER. We arrived at the hospital with the (patient #3) at 3:46 p.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, we were instructed by a staff ER nurse to take the patient to one of the "psych" rooms. As we were wheeling the patient toward the Psych room, (patient #3) took off his shoes and threw them at the doctor. My partner and I entered the Psych room and placed (patient #3) on the bed. At that point a female staff member, I am not sure if she was a doctor or a nurse practitioner, entered the room and said this patient was "banned" from LCMH and would not be seen in their facility. Hospital security was contacted and instructed to escort (patient #3) into the parking lot. The local police department was contacted to intervene once in the parking lot. The police officer that responded asked my partner and me if we would transport (patient #3) to (hospital "a") in Lake Charles which we did without further incident. Kindest Regards, (S16)..."

In a telephone interview on 01/24/13 at 1:55 p.m. with S17 (ambulance service "a") she stated that on 01/05/13 at 3:46 p.m. she and her partner arrived at the LCMH ER with patient #3. She stated when they entered the ER patient #3 (who was on the stretcher) removed one shoe and threw it at her, then removed the other and threw it at a nurse. She further stated that after patient #3 was placed on the hospital bed she went outside to the unit. S17 stated she heard a female nurse who was outside say that patient #3 was "banned". Patient #3 was outside at this point with Security and Police. S17 stated she did not know the name of the nurse but described her as a "blonde, pretty nurse." S17 stated her and her partner remained on the scene outside of the ER. S17 stated they were subsequently assigned to transport patient #3 to hospital "a". S17 stated a police officer rode in the ambulance module with her and patient #3 to hospital "a". S17 stated patient #3 gave them no problems. S17 stated she was in the ER less than 5 minutes and patient #3 was in the ER less than 15 minutes. S17 stated that PD1 began arriving "almost immediately after she went outside."

Review of a LCMH Security Department Incident Report revealed the following: "Security Officer Name: (S11Security). Date: 1/5/13. Type of Accident/Incident...Other: Unruly Patient. Person Involved: (patient #3)...Statement: I (S11Security), received a call on Jan. 5, 2013 from Kimberely [sp?] the charge nurse in the ER, staing [sp?] that there was a patient under the influence of PCP, urinating, spitting, and trying to break thing in the back of the ER. I then notified (S12Contracted Security Officer), to meet me in the back of the ER. I (S11Security) arrived on the scene at 15:56 (3:56 p.m.), S/O (security officer) (S12Contracted Security Officer) was already on the scene, I then asked head nurse Kimbere [sp?] for information on the situation. She stated the patient ' s name was (patient #3), who had been previously banned from Memorial, for repeated attempted violence against staff. (Patient #3) was brought in by ambulance, by order of (PD1), and he was spreading his bodily fluids, over the exam room, I approached (patient #3) cautiously, repeatedly asking (patient #3) to calm down. At 4:01 p.m., (PD1) had arrived on scene to take (patient #3), into custody. After consulating [sp?] with their superiors, the (PD1) officers, palced [sp?] (patient #3) in an (ambulance service "a"), to be transported to (hospital "a"), by way of police escort. No damage was done, noone [sp?] of the parties involved were injured. Incident end at 4:20 p.m. on Jan. 5, 2013..."

Review of a document provided by PD1 revealed a transcript of the 911 call placed from LCMH ED on 01/05/13 at 15:54 (3:54 p.m.) (8 minutes after ambulance service "a" arrived at the ED). Further review of this document revealed: "...Entry Day/Tm (time) 01/05/13 15:54:19. Call Type:...Disturbance/Fight...Lake Charles Memorial Hospital...Caller Name: ...(S3RN's first name)...Narrative: clr (caller) adv (advises) a big b/m (black male) about 6'1" banned from the hospital in the ER causing a big disturbance does not want to leave clr adv he is high and is throwing his shoes at people clr adv they want him removed from there for good...(entry time 16:19 (4:19 p.m.)) lcmh ill (still?) refusing care to this patient-following (ambulance service "a") unit 403 to (hospital "a") po (police officer) (name) riding in amb with patient."

In an interview on 01/23/13 at 9:53 a.m. with S4APRN-ANP she stated she had reviewed her statement from the hospital investigation and did remember patient #3. S4APRN-ANP stated that (ambulance service "a") had stopped near her desk with patient #3 on a stretcher at which time patient #3 removed his boot and threw it at her. S4APRN-ANP stated that there are other medical conditions in addition to a psychiatric condition which can cause the behaviors she observed. S4APRN-ANP further stated that within minutes she observed (PD1) escorting patient #3 out of the ED, possibly in handcuffs but she was not sure. S4APRN-ANP stated she thought patient #3 was being taken to jail. S4APRN-ANP stated that she see ' s patients after they are registered and appear on the computer. S4APRN-ANP stated that patient #3 was inside of the psychiatric room with the door closed and she did not hear any of the conversation inside of that room. She further stated she was not aware if the ED Physician made contact with patient #3.

In an interview on 01/23/13 at 11:50 a.m. with S5RN, ER, she stated she was on duty on 01/05/13 during the afternoon when patient #3 was brought into the ER. S5RNERstated she was assigned to a different area of the ER but did see patient #3 throw a boot when he was brought in. She stated patient #3 was on a stretcher. She further stated that she returned to the back of the ER but could still hear patient #3. S5RN ER stated that S3RN told patient #3 to "calm down" and that he "could not be urinating in the ER." S5RN ER stated she moved to the area where patient #3 was but did not have him in sight. S5RN ER stated the next thing she knew (PD1) was present in the ER telling patient #3 to calm down. S5RN ER stated she went outside and saw (PD1) taking patient #3 out of the ER. S5RN ER stated she "does not think" the patient was handcuffed and stated she had no idea if patient #3 was ever seen by an RN, MD, MHS (mental health specialist), or APRN. S5RN ER further stated "we have to see all patients regardless of why they are here and evaluate them." S5RN ER was asked if a "Code Greenjeans" was called and she replied "Not that I recall. There are not many Code Greenjeans in the ER because we usually handle it."

In an interview on 01/23/13 at 12:00 noon with S3RN she stated that she remembers the incident on 01/05/13. S3RN stated it was a Saturday and patient #3 arrived with (ambulance service "a") and they rolled him to the end of the nursing station. S3RN stated patient #3 threw a boot at S4APRN-ANP and kicked a COW (computer on wheels). S3RN stated that the ambulance crew placed patient #3 in the psyc (4 bed bay for psychiatric patients) room. S3RN stated she told patient #3 he could either calm down or be escorted off the premises by the police department. S3RN stated patient #3 responded "f#** you bitch" and began sliding off the end of the bed. S3RN stated she walked out and called the police department "to come pick up the patient." S3RN stated she then went to the side of the room where she could see patient #3 and he was urinating and spitting. S3RN stated patient #3 was then masturbating. S3RN stated Security and staff were all outside if the room and patient #3 was inside the room. S3RN stated PD1 arrived in 7 to 10 minutes (the 911 call transcript has the first unit on scene in 4 minutes). S3RN stated (PD1) escorted the patient out of the ER. S3RN stated there were 7 or 8 police officers outside with patient #3. S3RN stated that (PD1) asked her what she wanted them to do with patient #3 and she replied "take him away, he does not want to be seen here, I guess take him to jail." S3RN stated she overheard the police "talking to someone about an OPC (order for protective custody)." S3RN acknowledged that an OPC does not specify which hospital the patient is to be brought. S3RN was asked about the call she placed to (PD1). She stated she called the "direct line." S3RN stated she told the police that patient #3 was "acting up." S3RN was advised that the surveyor had a transcript of the call. S3RN denied she used the word "banned" in the call. S3RN stated that she did not call a Code Greenjeans because patient #3 was not being violent, he was being "inappropriate." S3RN confirmed that patient #3 was not registered in the computer system and there was no documentation of an assessment. S3RN was asked what could cause the behaviors displayed by patient #3 and she replied "drugs, mental illness, not taking his meds, [DIAGNOSES REDACTED], metabolic problems." S3RN stated she did inform hospital security that patient #3 was "banned" from this hospital previously. S3RN stated that she believed patient #3 did have the mental capacity to know what he was doing was wrong. S3RN confirmed that no physician or nurse practitioner ever saw patient #3. S3RN stated "if the patient does not want to be seen then by law I can't make him stay." S3RN stated that the "behavior and size" of patient #3 concerned her and that "someone" had informed her that patient #3 had been violent before. S3RN stated that she was "scared" of patient #3.

In an interview on 01/23/13 at 12:45 p.m. with S6MHS he stated he was on duty on 01/05/13 in the ER when patient was brought in during the afternoon. S6MHS stated he saw patient #3 throw a shoe at S4APRN-ANP. S6MHS stated he left the ER to bring a patient upstairs and when he returned patient #3 was outside with the police.

In an interview on 01/22/13 at 12:00 noon with S1CNO she stated that she learned of the incident from 01/05/13 on Monday January 7, 2013 from hospital "a". She stated that the staff of LCMH ER generated no incident reports concerning patient #3. S1CNO stated she did not know if there was video of the incident. It was later confirmed that there are video cameras in the ambulance bay but the DVR only holds the video for approximately 13 days before it is overwritten. It was revealed in an observation of the data on the DVR on 01/22/13 at 2:05 p.m. with S1CNO, S2ER Director, S9VP Operations and S10Security that 01/05/13 had been overwritten but was available for approximately 13 days after the incident. S1CNO confirmed the video was not reviewed during her investigation of the incident.

In an interview on 01/23/13 at 11:30 a.m. with S11Security he stated he was called to the ER on 01/05/13 when patient #3 was in the ER. S11Security stated that S3RN told him patient #3 "was on PCP" and that patient #3 was "banned" from the ER for previous violence against nursing staff. S11Security stated that no Code Greenjeans was called. S11Security stated patient #3 was not violent at any point during the incident. S11Security stated PD1 was called prior to hospital security being notified. S11Security stated that hospital security usually determines the need for PD1. S11Security stated he would not have called PD1 in this incident because patient #3 was not violent. S11Security stated that he "has no idea why the patient was taken out of one hospital and taken to another." He further stated "this hospital was refusing to treat the patient because S3RN said he was "banned." S11Security stated the police were asking what needed to be done and spoke to S3RN. S11Security stated that PD1 began showing up 5 minutes after being called. S11Security stated that S3RN said she called PD1 for staff protection.

In an interview on 01/24/13 at 12:10 p.m. with S13MD ER, he stated that he was on duty in the ER on 01/05/13 at 3:46 p.m. when patient #3 was brought to the LCMH ER. S13MD ER stated that no one told him anything about patient #3 prior to the departure of patient #3. S13MD ERstated patient #3 should have had a Medical Screening Exam. S13MD ER stated he would have stopped the police/security from removing patient #3 from the ER if he was aware of the situation. S13MD ER stated he would have seen the patient immediately. S13 MD ER was asked if he knew of the patient being "banned." S13MD ER stated he "heard someone say that (patient #3) was banned from the property."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer for 01/05/13 for the 3:46 p.m. arrival via ambulance.

During the same interview S1CNO was asked if any part of her investigation revealed that patient #3 was "banned" from the ER. She stated only as it relates to being dropped from a physicians service after an ICU (intensive care unit) stay.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record (registration, triage, assessment, interventions, medical screening exam, treatment, discharge) of patient #3 being at the ER for this ambulance arrival on 01/05/13 at 3:36 p.m.

Patient #5:
Review of the "Clinical Report-Nurse" notes revealed Patient #5 arrived at admitting on 12/28/12 at 7:30 p.m. and was triaged at 7:38 p.m. with a chief complaint of "Depression and Anxiety and Thoughts of Harming Self (cutting)" and an acuity level of "3" was assigned by the nurse. Patient #5 waited in the waiting room area for eight minutes prior to the emergency room nurse performing a triage assessment of the patient on 12/28/12.

Further review of the "Clinical Report-Nurse" notes at 7:45pm revealed Patient #5 answered "yes" to the following questions: Do you have thoughts of harming or killing yourself? Are you here because you tried to hurt yourself today?". Patient #5 was sent to the waiting room at 7:45 p.m.. Patient #5 was assessed by a Mental Health Specialist at 8:15 p.m. Patient #5 was ambulatory to room at 9:29 p.m. Patient #5 waited in the waiting room for thirty minutes upon arrival to the emergency room and for one hour and fourteen minutes prior to being brought to a room to be seen by the emergency room physician on 12/28/12.

Review of the "Clinical Report-Physician/Mid Level" date/time seen 12/28/12 at 8:56 p.m. revealed Patient #5's chief complaint was "Depressed and Suicidal Thoughts....Has been depressed and suicidal thoughts....The patient inflicted self-injury (superficial lacerations to L FA)-left forearm....The symptoms are described as severe...Past history: Depression....(had psyc admit for cutting as teen)....Prior history of suicide attempt..." and was assigned an acuity level of "3".

During an interview on 01/29/13 from 10:40 a.m. through 10:51 a.m., S1CNO and S2ER, Director both confirmed Patient #5 arrived to the emergency department on 12/28/12 at 7:31pm with a chief complaint of "Depression and Anxiety and Thoughts of Harming Self (cutting)". S1CNO and S2ER, Director both verified Patient #7 had no triage assessment performed by an emergency room nurse from 7:30pm through 7:38pm for eight minutes as per policy. S2ER, Director indicated Patient #5 sat in the waiting room for eight minutes without an initial assessment being performed on 12/28/12 as per policy. S2ER, Director verified Patient #5's acuity level was a "3"-Urgent and should have been a level "2" as per policy.

Patient #7's first visit on 12/26/12:
Review of the "Clinical Report-Nurse" notes revealed Patient #7 arrived at admitting on 12/26/12 at1:20 a.m. was triaged at 1:22 a.m. with chief complaints of "Bizarre Behavior" and an acuity level of "3"- Urgent assigned by the nurse.

During an interview on 01/29/13 at 11:20 a.m., S1CNO and S2ER, Director both confirmed Patient #7 arrived to the emergency department on 12/26/12 at 01:20am with a chief complaint of "Bizarre Behavior". S1CNO and S2ER, Director both verified Patient #7 had an acuity level of "3" assigned by the nurse on 12/26/12. S2ER, Director indicated the nurse failed to assign Patient #7 an acuity level of "2" as per policy.

Patient #7's second visit on 12/28/12:
Review of the "Clinical Report-Nurse" notes revealed Patient #7 arrived at admitting on 12/28/12 at 1:23 p.m. was triaged at 1:26 p.m. with chief complaints of "suicidal thoughts and audio hallucinations". Patient #7 had an acuity level of "3"-Urgent assigned by the nurse, was put in a treatment room, and had safety precautions initiated with 1:1 (one-to-one) supervision at 1:29 p.m.

Further review of the medical record revealed Patient #7 had no triage assessment performed by an emergency room nurse from 1:23pm through 1:26 pm for three minutes on 12/28/12.

During an interview on 01/29/13 at 11:20 a.m., S1CNO and S2ER, Director both confirmed Patient #7 arrived to the emergency department on 12/28/12 at 1:23pm with a chief complaint of "suicidal thoughts and audio hallucinations." S1CNO and S2ER, Director both verified Patient #7 had no triage assessment performed by an emergency room nurse from 1:23pm through 1:26pm for three minutes on 12/28/12. S2ER, Director indicated the nurse failed to follow policy for the initial assessment to be performed within minutes of arrival to the emergency room and assign Patient #7 an acuity level of "2" as per policies.

Patient #8:
Review of the "Face Sheet" revealed Patient #8 arrived at admitting on 01/01/13 at 4:40 p.m. with a chief complaint of "suicidal".

Review of the "Clinical Report-Nurse" revealed Patient #8 arrived to admitting at 4:39 p.m.) on 01/01/13. Further review revealed Patient #8 left the emergency department before registration and triage at 5:33 p.m. There was no triaged assessment performed by an emergency room nurse on Patient #8 from 4:40 through 5:33 for fifty-four minutes on 01/01/13.

During an interview on 01/29/13 at 11:25 a.m., S1CNO and S2ER, Director both confirmed Patient #8 arrived to the emergency department on 01/01/13 at 4:39pm with a chief complaint of "suicidal". S1CNO and S2ER, Director both verified there was no triage assessment and/or an acuity level of "2" assigned to Patient #7 for fifty-four minutes on 01/01/13 as per policy. S2ER, Director verified Patient #7 failed to have an initial assessment (triage) by an emergency room nurse for fifty-four (54) minutes on 01/01/13 as per policy.

Patient #9:
Review of the "Clinical Report-Nurse" notes revealed Patient #9 arrived to the emergency room on [DATE] at 8:27 p.m., was triaged at 8:28 p.m. with a chief complaint of "Suicidal Thoughts" and had an acuity level of "3" assigned by the nurse at 8:28 pm, was sent to the waiting room at 8:33 p.m., and was ambulatory to room at 9:35 p.m.

During an interview on 01/29/13 at 10:55 a.m., S1CNO and S2ER, Director both confirmed Patient #9 arrived to the emergency department on 01/04/13 at 8:27 with a chief complaint of "Suicidal Thoughts" and "thoughts of harming or killing herself". S2ER, Director verified Patient #9's acuity level was a "3" on 01/04/13. S1CNO and S2ER, Director both indicated Patient #9's acuity level should had been a "2" as per policy.

Patient #11:
Review of the "Face Sheet" revealed Patient #11 arrived at admitting on 01/04/13 at 11:28 p.m. with a chief complaint of "Psych Evaluation".

Review of the "Patient Log" for the emergency department revealed Patient #11 arrived at admitting at 11:28 pm with a chief complaint of "Psyc Evaluation" and left prior to triage (LPT) at 11:34 p.m. on 01/04/13.

Review of the medical record revealed there was no "Clinical Report-Nurse" notes for Patient #11 on 01/04/13. Further review revealed Patient #11 had no triage assessment performed by an emergency room nurse from 11:28pm through 11:34pm for six (6) minutes on 01/04/13.

During an interview on 01/29/13 at 11:40 a.m., S1CNO and S2ER, Director both confirmed Patient #11 arrived to the emergency department on 01/04/13 at 11:28pm with a chief complaint of "Psyc Evaluation". S1CNO and S2ER, Director both verified Patient #11 had no triage assessment performed from 11:28pm through 11:34pm for six minutes on 01/04/13 as per policy.

Patient #12:
Review of the "Face Sheet" revealed Patient #12 arrived to admitting on 01/06/13 at 3:22 p.m. with a chief complaint of "Psych Evaluation".

Review of the "Clinical Report-Nurse" notes revealed Patient #12 arrived at admitting on 01/06/13 at 3:22, pm was triaged at 3:33 p.m. with a chief complaint of "Substance Abuse", was assigned an acuity level of "3" by the nurse at 3:33pm, was sent to waiting room at 3:38 p.m. and the patient left without being seen by a physician and without signing a form at 7:49 p.m

Further review of the medical record revealed there was no triage assessment by an emergency room nurse from 3:22pm through 3:33pm for eleven minutes on 01/06/13.

During an interview on 01/29/13 at 11:43 a.m., S1CNO and S2ER, Director both confirmed Patient #12 arrived to the emergency department on 01/06/13 at 3:22pm with a chief complaint of "Substance Abuse". S1CNO and S2ER, Director both verified Patient #12 had no triage assessment performed by an emergency room nurse from 3:22pm through 3:33 pm for eleven minutes on 01/06/13 as per policy. S2ER, Director confirmed Patient #12 had an acuity level of "3" assigned by the nurse and it should have been a level "2" on 01/06/13 as per policy.

Patient #13:
Review of the "Face Sheet" revealed Patient #13 arrived to the emergency department on 01/09/13 at 12:16 p.m. with a chief complaint of "Substance misuse".

Review of the "Patient Log" revealed Patient #13 arrived to the emergency department on 01/09/13 at 12:15 p.m. with a chief complaint of "Substance misuse/Intoxification" and left prior to triage (LPT) at 12:34 p.m.

Review of the "Clinical Report-Nurse" notes revealed Patient #13 arrived to admitting on 01/09/13 at 12:16 p.m. with a chief complaint of "Thoughts of Harming Self" with no triage assessment and/or triage acuity level assignment performed by an emergency room nurse from 12:16 pm. through 9:20 a.m. for twenty-one hours and nineteen minutes on 01/09/13. The disposition/discharge vital signs (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and pain level sections were deferred by S21ER, Tech at 09:20-the next morning, 01/10/13.

There was no documentation Patient #13 had an initial assessment performed by an emergency room nurse from 12:15pm through 9:20am - the next day, 01/10/13, for twenty-one hours and nineteen minutes on 01/09/13.

During an interview on 01/29/13 at 11:29 a.m., S1CNO and S2ER, Director both confirmed Patient #13 arrived to the emergency department on 01/09/13 at 12:16pm with a chief complaint of "Substance misuse" and "Thoughts of Harming Self". S2ER, Director verified there was no documented evidence Patient #13 had an initial assessment performed by an emergency room nurse from 12:15pm through 09:20am for twenty-one hours and nineteen minutes on 01/09/13 as per policy.

Patient #16:
Review of the "Clinical Report-Nurse" notes revealed Patient #16 arrived at admitting on 01/13/13 at 7:41 p.m. was triaged at 7:46 p.m. with a chief complaint of "very aggressive behavior" and "out of control" at 7:46, had an acuity level of "3" assigned by the nurse, answered "yes" to "Do you have thoughts of harming or killing yourself?" at 7:52 p.m., and left the emergency department without being seen (LWBS) by a physician at 9:04 p.m.

Further review of the medical record revealed there was no triage assessment performed by an emergency room nurse on Patient #17 from 7:41pm through 7:46pm for five minutes on 01/13/13.

During an interview on 01/29/13 at 11:35 a.m., S1CNO and S2ER, Director both confirmed Patient #16 arrived to the emergency department on 01/13/13 at 7:41 p.m. with a chief complaints of "very aggressive behavior" and "out of control" and with "thoughts of harming or killing yourself". S2ER, Director indicated Patient #16 should have been assigned an acuity level of "2" as per policy. S2ER, Director confirmed there was no triage assessment of Patient #17 from 7:41pm through 7:46pm for five minutes on 01/13/13 as per policy.

Patient #17:
Review of the "Patient Log" revealed Patient #17 arrived at the emergency department on 01/14/13 at 3:20 p.m. with a chief complaint of "Psych Evaluat
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the hospital failed to ensure the development and implementation of an Abuse Prohibition policy. Findings:

In an interview on 01/29/13 at 10:35 a.m. with S1CNO a request was made for a copy of the hospital's Abuse Prohibition policy. S1CNO presented the hospital's policies on Elderly Abuse, Child Abuse, Domestic Abuse and Spousal Abuse. S1CNO stated the hospital had no policy that defined "neglect". S1CNO stated she could not state the hospital's definition of neglect. S1CNO confirmed the hospital has no written Abuse Prohibition policy as described in 42 CFR 482.13(c) (3).
VIOLATION: PATIENT SAFETY Tag No: A0286
Review of the hospital's Quality Assurance Data for tracking patients that left the ER prior to being seen by a physician or Nurse Practitioner revealed the system in place was failing to accurately track and trend these patients as evidenced by the hospital having identified two (2) patients (#9, #12) of 15 psychiatric patients reported daily to administration (#8, #9, #12, #13, #15, #16, #17, #18, #19, #21) out of a total sample of 21 (#1 - #21) patients and 0 (R1, R7, R9, R11, R24) of 5 (#R1 - #R24) random sampled patients focused records reviewed for psychiatric diagnosis and left prior to registration, left prior to triage, left without being seen by a physician, walked out, and/or left against medical advice (AMA) from 01/01/13 through 01/18/13 as identified by the surveyor on 01/30/13.

Findings:

Review of the "Patient Logs" from 01/01/13 through 01/18/13 revealed the following:

01/01/13- there were two (2) psychiatric patients (#8 and #R1) who presented to the emergency department for treatment;

01/04/13-there were two (2) psychiatric patients (#9, #R11) who presented to the emergency department for treatment;

01/06/13- there were three (3) psychiatric patients (#R7, #12, R9) who presented to the emergency department for treatment;

01/09/13-there were (3) psychiatric patients, (#13, #15, #21) who presented to the emergency department for treatment;

01/13/13-there was one (1) psychiatric patient (#16) who presented to the emergency department for treatment;

01/14/13- there were (2) psychiatric patients (#17, #18) who presented to the emergency department for treatment;

01/16/13- there was (1) psychiatric patient (#19) who presented to the emergency department for treatment; and

01/18/13- there was (1) psychiatric patient (#R24) who presented to the emergency department for treatment.

There were a total of fifteen (15) psychiatric patients (#8, #9, #12, #13, #15, #16, #17, #18, #19, #21, #R1, #R7, #R9, #R11, #24) that presented to the emergency department for treatment from 01/01/13 through 01/18/13.

Review of the emails dated 01/01/13 through 01/18/13 revealed there were (2) psychiatric patients (#9, #12) reported to administration on 01/04/13 (#9) and 01/06/13 (#12) for the month of January, 2013.

In an interview 01/28/13 at 10:00 a.m., S21ER, Tech indicated there is daily reporting of all psychiatric patients to administration in an email as per protocol. S21ER, Tech verified there were two (2) psychiatric patients (#9, #12) that were reported to administration on 01/04/13 and 01/06/13 in an email. S21ER, Tech indicated there was total of (2) psychiatric patients (#9, #12) reported to administration for the month of January, 2013.

During an interview on 01/29/13 at 11:55 a.m., S1CNO confirmed there were 15 psychiatric patients (#8, #9, #12, #13, #15, #16, #17, #18, #19, #21, #R1, #R7, #R9, #R11, #24) that presented to the emergency with a psychiatric diagnosis and left prior to registration, left prior to triage, left without being seen by a physician, walked out, and/or left against medical advice (AMA) from 01/01/13 through 01/18/13. S1CNO indicated there is no accurate tracking, trending, monitoring, and/or reporting of the 15 psychiatric patients and/or high risks patients presenting to the emergency room who left prior to registration, who left prior to triage, who left without being seen by physician, who walked out, and/or who left AMA from 01/01/13 through 01/18/13.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on record review and interview the hospital failed to meet the Condition of Participation for Emergency Services as evidenced by:

1) failing to ensure patients were triaged in a timely manner after presentation to the emergency room in order to assure patients at risk to themselves or others were identified as per hoapital policy for 13 (#3 -2 visits on 01/05/13 1:46 a.m. and on 01/05/13 3:46 p.m.), #5, #7's -2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A1104)

2) failing to ensure hospital policy of 1:1 supervision was put into place and maintained for patients with a chief complaint or assessment findings of danger to self or others for 13 (#3 (2 visits on 12/09/12 and on 12/10/12), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A1104)

3) failing to ensure patients that presented to the emergency room considered to be a risk to themselves or others were assessed by an emergency room physician as per policy for 10 (#7's visit on 12/28/12 visit, #8, #9, #11, #12, #13, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 -#R24). (see findings at A1104)

4) failing to ensure patients considered to be a risk to themselves or others had a Mental Health Assessment after presentation to the emergency room performed as per policy for 11 (#7's visit on 12/28/12, #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients and 1 (#R1) of 24 random sampled patients (#R1 - #R24). (see findings at A1104)
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the hospital failed to ensure the policy and procedure governing medical care in the emergency room (ER) were followed as evidenced by failing to:

1) failing to ensure patients were triaged in a timely manner after presentation to the emergency room in order to assure patients at risk to themselves or others were identified as per policy for 13 (#3 -2 visits on 01/05/13 1:46 a.m. and on 01/05/13 3:46 p.m.), #5, #7's -2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

2) failing to ensure hospital policy of 1:1 supervision was put into place and maintained for patients with a chief complaint or assessment findings of danger to self or others for 13 (#3 (2 visits on 12/09/12 and on 12/10/12), #5, #7 (2 visits on 12/26/12 and on 12/28/12), #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

3) failing to ensure patients that presented to the emergency room considered to be a risk to themselves or others were assessed by an emergency room physician as per policy for 10 (#7's visit on 12/28/12 visit, #8, #9, #11, #12, #13, #17, #18, #19, #21) of 21 sampled patients (#1 - #21) and 1 (#R1) of 24 random sampled patients (#R1 -#R24).

4) failing to ensure patients considered to be a risk to themselves or others had a Mental Health Assessment after presentation to the emergency room performed as per policy for 11 (#7's visit on 12/28/12, #8, #9, #11, #12, #13, #16, #17, #18, #19, #21) of 21 sampled patients and 1 (#R1) of 24 random sampled patients (#R1 - #R24).

Findings:

Patient #3

Review of ambulance run reports for 01/05/13 from ambulance service "a" revealed patient #3 was transported twice to Lake Charles Memorial Hospital (LCMH) on 01/05/13 and once to hospital "a" on 01/05/13. Review of the LCMH ER Central Log revealed the hospital has no documentation of either arrival of patient #3 on 01/05/13.

FIRST VISIT OF PATIENT #3 ON 01/05/13 AT 1:46 a.m.

Review of the first ambulance run report revealed in part: "Incident 911. Date: 01/05/2013. Patient: (patient #3). Complaint: Behavioral...Patient found: pt was sitting in a carport talking to pd (police department) and was in just his underwear...History of Present Illness...Description: pt was sleeping in his mother shed and had been for days pt had stop taking his meds pt was in just his underwear sitting outside...Past Medical History: psychiatric, bipolar...Observation and Exam. Secondary Conditions for Ambulance Transport: Hallucinations, Paranoia...Dispatch Time: Clock Start 01:30 (1:30 a.m.)...Arrive at Hospital: 01:46 (1:46 a.m.)."

Review of a statement from ambulance service "a" crew member S19 revealed the following: "...Incident # 911. (ambulance service "a") Crew: S18/S19 (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2012, my partner and I transported patient (#3) to the Lake Charles Memorial ER from his residence in Lake Charles. We arrived at the hospital with the patient at 1:46 a.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, I was instructed by an ER staff nurse that the patient was being triaged and that I should bring him to the ER lobby. My partner and I brought him to the ER lobby, had him sit in a chair, I gave his demographic information to the ER admit clerk, and my partner and I departed the hospital. Respectfully, (S19)..."

Review of a statement from S15Supervisor (ambulance service "a") revealed the following: "Incident # 911. (ambulance service "a") Crew: (S18)/(S19) (Unit 402). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, Unit 402 transported (patient #3) from his residence to the Lake Charles Memorial Hospital ER. CAD (Computer Aided Dispatch) tracking by GPS (global positioning satellite) shows that they arrived at LCMH at 01:46:34 (1:46 a.m.). Respectfully, (S15)..."

In an interview on 01/23/13 at 2:00 p.m. with S1CNO she was shown a copy of the ambulance run report indicating patient #3 was brought to LCMH ER at 1:46 a.m. on 01/05/13. S1CNO stated she "would have to look into it."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer at all for 01/05/13 for his 1:46 a.m. arrival via ambulance.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record (registration, triage, assessment, interventions, medical screening exam, treatment, discharge) of patient #3 being at the ER for this ambulance arrival on 01/05/13 at 1:46 a.m.

SECOND VISIT OF PATIENT #3 ON 01/05/13 AT 3:46 p.m.

Review of the second run report revealed in part: "Incident 092. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 2XXX Anita Dr. Lake Charles, LA...Destination: LCMH...Patient Found: PT found outside talking to police...History of Present Illness...Description: Police called (ambulance service "a") for a psych pt that needed to be evaluated. Police state the pt was walking around a neighborhood pointing at people and saying bizarre things. Pt states he takes psych meds but he ran out. Pt also states he smoked some marijuana...Past Medical History...Psychiatric...Observation and Exam...Secondary Conditions for Ambulance Transport: Unmanageable behavior, Restraints; to prevent harm to self/others, hallucinations...(no vital signs documented)...Response to Treatment...Additional Narrative: During transport to the hospital the pt would talk to himself and say bizarre things and laugh. Pt refused vitals and pt refused to talk to me. Once we arrived at the ED we brought the pt inside and was assigned a psych room. Enroute to the psych room the pt would constantly say bizarre things and at one point he took his shoes off and threw them at a doctor. Once we put the pt in the psych room a nurse came in and said he was "banned" from this hospital and that he could not be seen here. Police were called to ED and the pt was escorted out of the ED. We then had to transport the pt to (hospital "a") (Inc # 190). Dispatch Time: Clock Start 15:26 (3:26 p.m.)...Arrive at hospital 15:46 (3:46 p.m.)."

Review of the third run report revealed in part: "Incident 192. Date: 01/05/2013. Patient: (patient #3). Complaint: PSYCH...Origin: 1XXX Oak Park Blvd. Lake Charles, LA (LCMH)...Destination: (hospital "a")...Patient Found: ambulatory at scene...History of Present Illness...Description: 33 y/o male being transported to (hospital "a") for a psych evaluation. (PD1) requested the patient be "checked out" due to bizarre behavior and the pt stated he was out of his meds...Past Medical History...Psychiatric, bipolar, schizophrenia...Observation and Exam...Secondary Conditions for Ambulance Transport: hallucinations...Response to Treatment...Additional Narrative: Pt was unwilling to sign sig (signature) page. Pt was initially transported to Lake Charles Memorial Hospital for treatment
but they refused to evaluate the patient. They requested the patient be escorted off the property by (PD1). Transportation to (hospital "a") was without incident. Transfer of care to (hospital "a") was without incident. Dispatch Time: Clock Start 16:19 (4:19 p.m.)...Arrive at hospital 16:26 (4:26 p.m.)."

Review of a statement from S16 (ambulance service "a") revealed the following: "...Incident # 092. (ambulance service "a") Crew: (S16/S17) (Unit 403). Patient: (patient #3). To Whom It May Concern: On January 5, 2013, my partner and I transported patient (Patient #3) to the Lake Charles Memorial Hospital ER. We arrived at the hospital with the (patient #3) at 3:46 p.m. I was the medic responsible for riding in the module of the ambulance with the patient and I completed the medical record. When we entered the LCMH-ER with the patient, we were instructed by a staff ER nurse to take the patient to one of the "psych" rooms. As we were wheeling the patient toward the Psych room, (patient #3) took off his shoes and threw them at the doctor. My partner and I entered the Psych room and placed (patient #3) on the bed. At that point a female staff member, I am not sure if she was a doctor or a nurse practitioner, entered the room and said this patient was "banned" from LCMH and would not be seen in their facility. Hospital security was contacted and instructed to escort (patient #3) into the parking lot. The local police department was contacted to intervene once in the parking lot. The police officer that responded asked my partner and me if we would transport (patient #3) to (hospital "a") in Lake Charles which we did without further incident. Kindest Regards, (S16)..."

In a telephone interview on 01/24/13 at 1:55 p.m. with S17 (ambulance service "a") she stated that on 01/05/13 at 3:46 p.m. she and her partner arrived at the LCMH ER with patient #3. She stated when they entered the ER patient #3 (who was on the stretcher) removed one shoe and threw it at her, then removed the other and threw it at a nurse. She further stated that after patient #3 was placed on the hospital bed she went outside to the unit. S17 stated she heard a female nurse who was outside say that patient #3 was "banned". Patient #3 was outside at this point with Security and Police. S17 stated she did not know the name of the nurse but described her as a "blonde, pretty nurse." S17 stated her and her partner remained on the scene outside of the ER. S17 stated they were subsequently assigned to transport patient #3 to hospital "a". S17 stated a police officer rode in the ambulance module with her and patient #3 to hospital "a". S17 stated patient #3 gave them no problems. S17 stated she was in the ER less than 5 minutes and patient #3 was in the ER less than 15 minutes. S17 stated that PD1 began arriving "almost immediately after she went outside."

Review of a LCMH Security Department Incident Report revealed the following: "Security Officer Name: (S11Security). Date: 1/5/13. Type of Accident/Incident...Other: Unruly Patient. Person Involved: (patient #3)...Statement: I (S11Security), received a call on Jan. 5, 2013 from Kimberely [sp?] the charge nurse in the ER, staing [sp?] that there was a patient under the influence of PCP, urinating, spitting, and trying to break thing in the back of the ER. I then notified (S12Contracted Security Officer), to meet me in the back of the ER. I (S11Security) arrived on the scene at 15:56 (3:56 p.m.), S/O (security officer) (S12) was already on the scene, I then asked head nurse Kimbere [sp?] for information on the situation. She stated the patient ' s name was (patient #3), who had been previously banned from Memorial, for repeated attempted violence against staff. (Patient #3) was brought in by ambulance, by order of (PD1), and he was spreading his bodily fluids, over the exam room, I approached (patient #3) cautiously, repeatedly asking (patient #3) to calm down. At 16:01 (4:01 p.m.), (PD1) had arrived on scene to take (patient #3), into custody. After consulating [sp?] with their superiors, the (PD1) officers, palced [sp?] (patient #3) in an (ambulance service "a"), to be transported to (hospital "a"), by way of police escort. No damage was done, noone [sp?] of the parties involved were injured. Incident end at 16:20 (4:20 p.m.) on Jan. 5, 2013..."

Review of a document provided by PD1 revealed a transcript of the 911 call placed from LCMH ED on 01/05/13 at 15:54 (3:54 p.m.) (8 minutes after ambulance service "a" arrived at the ED). Further review of this document revealed: "...Entry Day/Tm (time) 01/05/13 15:54:19. Call Type:...Disturbance/Fight...Lake Charles Memorial Hospital...Caller Name: ...(S3RN's first name)...Narrative: clr (caller) adv (advises) a big b/m (black male) about 6'1" banned from the hospital in the ER causing a big disturbance does not want to leave clr adv he is high and is throwing his shoes at people clr adv they want him removed from there for good...(entry time 16:19 (4:19 p.m.)) lcmh ill (still?) refusing care to this patient-following (ambulance service "a") unit 403 to (hospital "a") po (police officer) (name) riding in amb with patient."

In an interview on 01/23/13 at 9:53 a.m. with S4APRN-ANP she stated she had reviewed her statement from the hospital investigation and did remember patient #3. S4APRN-ANP stated that (ambulance service "a") had stopped near her desk with patient #3 on a stretcher at which time patient #3 removed his boot and threw it at her. S4APRN-ANP stated that there are other medical conditions in addition to a psychiatric condition which can cause the behaviors she observed. S4APRN-ANP further stated that within minutes she observed (PD1) escorting patient #3 out of the ED, possibly in handcuffs but she was not sure. S4APRN-ANP stated she thought patient #3 was being taken to jail. S4APRN-ANP stated that she see's patients after they are registered and appear on the computer. S4APRN-ANP stated that patient #3 was inside of the psychiatric room with the door closed and she did not hear any of the conversation inside of that room. She further stated she was not aware if the ED Physician made contact with patient #3.

In an interview on 01/23/13 at 11:50 a.m. with S5RN, ER, she stated she was on duty on 01/05/13 during the afternoon (3:46 p.m.) when patient #3 was brought into the ER. S5RN stated she was assigned to a different area of the ER but did see patient #3 throw a boot when he was brought in. She stated patient #3 was on a stretcher. She further stated that she returned to the back of the ER but could still hear patient #3. S5RN stated that S3RN told patient #3 to "calm down" and that he "could not be urinating in the ER." S5RN stated she moved to the area where patient #3 was but did not have him in sight. S5RN stated the next thing she knew (PD1) was present in the ER telling patient #3 to calm down. S5RN stated she went outside and saw (PD1) taking patient #3 out of the ER. S5RN stated she "does not think" the patient was handcuffed. S5RN stated she had no idea if patient #3 was ever seen by an RN, MD, MHS (mental health specialist), and/or APRN. S5RN further stated "we have to see all patients regardless of why they are here and evaluate them." S5RN was asked if a "Code Greenjeans" was called and she replied "Not that I recall. There are not many Code Greenjeans in the ER because we usually handle it."

In an interview on 01/23/13 at 12:00 noon with S3RN she stated that she remembers the incident on 01/05/13. S3RN stated it was a Saturday and patient #3 arrived with (ambulance service "a") and they rolled him to the end of the nursing station. S3RN stated patient #3 threw a boot at S4APRN and kicked a COW (computer on wheels). S3RN stated that the ambulance crew placed patient #3 in the psyc (4 bed bay for psychiatric patients) room. S3RN stated she told patient #3 he could either calm down or be escorted off the premises by the police department. S3RN stated patient #3 responded "f#** you bitch" and began sliding off the end of the bed. S3RN stated she walked out and called the police department "to come pick up the patient." S3RN stated she then went to the side of the room where she could see patient #3 and he was urinating and spitting. S3RN stated patient #3 was then masturbating. S3RN stated Security and staff were all outside of the room and patient #3 was inside the room. S3RN stated PD1 arrived in 7 to 10 minutes (the 911 call transcript has the first unit on scene in 4 minutes). S3RN stated (PD1) escorted the patient out of the ER. S3RN stated there were 7 or 8 police officers outside with patient #3. S3RN stated that (PD1) asked her what she wanted them to do with patient #3 and she replied "take him away, he does not want to be seen here, I guess take him to jail." S3RN stated she overheard the police "talking to someone about an OPC (order for protective custody)." S3RN acknowledged that an OPC does not specify which hospital the patient is to be brought. S3RN was asked about the call she placed to (PD1). She stated she called the "direct line." S3RN stated she told the police that patient #3 was "acting up." S3RN was advised that the surveyor had a transcript of the call. S3RN denied she used the word "banned" in the call. S3RN stated that she did not call a Code Greenjeans because patient #3 was not being violent, he was being "inappropriate." S3RN confirmed that patient #3 was not registered in the computer system and there was no documentation of a triage/initial assessment. S3RN was asked what could cause the behaviors displayed by patient #3 and she replied "drugs, mental illness, not taking his meds, [DIAGNOSES REDACTED], metabolic problems." S3RN stated she did inform hospital security that patient #3 was "banned" from this hospital previously. S3RN stated that she believed patient #3 did have the mental capacity to know what he was doing was wrong. S3RN confirmed that no physician or nurse practitioner ever saw patient #3. S3RN stated "if the patient does not want to be seen then by law I can't make him stay." S3RN stated that the "behavior and size" of patient #3 concerned her and that "someone" had informed her that patient #3 had been violent before. S3RN stated that she was "scared" of patient #3.

In an interview on 01/23/13 at 12:45 p.m. with S6MHS he stated he was on duty on 01/05/13 in the ER when patient was brought in during the afternoon. S6MHS stated he saw patient #3 throw a shoe at S4APRN. S6MHS stated he left the ER to bring a patient upstairs and when he returned patient #3 was outside with the police.

In an interview on 01/22/13 at 12:00 noon with S1CNO she stated that she learned of the incident from 01/05/13 on Monday January 7, 2013 from hospital "a", 2 days after the incident. She stated that the staff of LCMH ER generated no incident reports concerning patient #3. S1CNO stated she did not know if there was video of the incident. It was later confirmed that there are video cameras in the ambulance bay but the DVR only holds the video for approximately 13 days before it is overwritten. It was revealed in an observation of the data on the DVR (digital video recorder) on 01/22/13 at 2:05 p.m. with S1CNO, S2ER Director, S9VP Operations and S10Security that 01/05/13 had been overwritten but was available for approximately 13 days after the incident. S1CNO confirmed the video was not reviewed during her investigation of the incident.

In an interview on 01/23/13 at 11:30 a.m. with S11Security he stated he was called to the ER on 01/05/13 when patient #3 was in the ER. S11Security stated that S3RN told him patient #3 "was on PCP" and that patient #3 was "banned" from the ER for previous violence against nursing staff. S11Security stated that no Code Greenjeans was called. S11Security stated patient #3 was not violent at any point during the incident. S11Security stated PD1 was called prior to hospital security being notified. S11Security stated that hospital security usually determines the need for PD1. S11Security stated he would not have called PD1 in this incident because patient #3 was not violent. S11Security stated that he "has no idea why the patient was taken out of one hospital and taken to another." He further stated "this hospital was refusing to treat the patient because S3RN said he was "banned." S11Security stated the police were asking what needed to be done and spoke to S3RN. S11Security stated that PD1 began showing up 5 minutes after being called. S11Security stated that S3RN said she called PD1 for staff protection.

In an interview on 01/24/13 at 12:10 p.m. with S13MD, ER, he stated that he was on duty in the ER on 01/05/13 at 3:46 p.m. when patient #3 was brought to the LCMH ER. S13MD stated that no one told him anything about patient #3 prior to the departure of patient #3 with PD1. S13MD stated patient #3 should have had a Medical Screening Exam. S13MD stated he would have stopped the police/security from removing patient #3 from the ER if he was aware of the situation. S13MD stated he would have seen the patient immediately. S13 MD was asked if he knew of the patient being "banned." S13MD stated he "heard someone say that (patient #3) was banned from the property."

In an interview on 01/23/13 at 2:05 p.m. with S1CNO and S21ER Tech it was confirmed by S21ER Tech that patient #3 was not registered in the computer for 01/05/13 for the 3:46 p.m. arrival via ambulance.

During the same interview on 01/23/13 at 2:05 p.m. S1CNO was asked if any part of her investigation revealed that patient #3 was "banned" from the ER. She stated only as it relates to being dropped from a physicians service after an ICU (intensive care unit) stay.

In a follow up interview on 01/24/13 at 11:36 a.m. with S1CNO and S2ER Director both confirmed that the hospital has no record (registration, triage, assessment, interventions, medical screening exam, treatment, discharge) of patient #3 being at the ER for this ambulance arrival on 01/05/13 at 3:36 p.m.

Review of patient #3's list of ER visits revealed patient #3 was also at Lake Charles Memorial Hospital on December 9th, and 10th, 2012. The following information was contained in the medical records for those visits:

December 9, 2012:

"...If unable to sign, Reason: mentally unstable/Refused to give any info...Triage time 21:13 (9:13 p.m.) [DATE]. Acuity: Level 3. Chief Complaint: Bizarre Behavior and (Found in the street acting like he was swimming on asphalt)...History: Admits to having hallucinations...(Patient states he smoked some holy water on a cigarette and now he's been hearing spirits.)...Disposition/Discharge 23:16 (11:16 p.m.) 12/09/12. The patient left the Emergency Department without being seen by a physician. Unable to locate patient. Patient paged three times with no response. The patient did not notify the ED staff prior to leaving the department. Notified the charge nurse of patient departure. Patient left without signing form prior to leaving..."

In an interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that there was no documented Suicide Risk Assessment, patient #3 should have been Triaged as a ESI Level 2, that the documentation does not indicate patient #3 was placed in a room with 1:1 supervision per hospital policy, there is no Mental Health screening per hospital policy, and no Medical Screening Exam was performed on patient #3.

December 10, 2012:

Triage Time 21:46 (9:46 p.m.) [DATE]. Chief Complaint: Bizarre Behavior. 21:49 (9:49 p.m.) 12/10/2012...History. Onset: today. (Patient was wandering in traffic.). Has been feeling agitated. Admits to having hallucinations. Past medical hx (history): Psychiatric illness...Additional Problems: Schizophrenia. Bipolar Disorder...Physical Assessment 22:00 (10:00 p.m.)...Patient's mood/affect appears hostile. Patient appears calm and cooperative. Behavior appears abnormal, including paranoid behaviors and having apparent auditory and visual hallucinations. The patient appears to have altered thought processes, verbalized as delusions of grandeur. Patient appears agitated...22:14 (10:14 p.m.)

12/10/2012. (security reports pt left ER, and was found laying behind an ambulance with a cane in his hands. Said pt stood up and took off running and could not catch patient.)...22:14 12/10/12. The patient left the Emergency Department without being seen by a physician. The patient appears to be uncooperative. Notified the ED Physician of a patient departure. The patient left the Emergency Department ambulatory..."

In an interview on 01/24/13 at 11:36 a.m. with S1CNO and S2RN, ER Director both confirmed that there was no documented Suicide Risk Assessment, patient #3 should have been Triaged as a ESI (emergency severity index) Level 2, that the documentation does not indicate patient #3 was placed on 1:1 supervision per hospital policy, there is no Mental Health screening per hospital policy, and no Medical Screening Exam was performed on patient #3 for his 12/09/12 and 12/10/12 ER visits.

Patient #5

Review of the "Clinical Report-Nurse" notes revealed Patient #5 arrived at admitting on 12/28/12 at 19:30 (7:30 p.m.), was triaged at 19:38 (7:38 p.m.) with a chief complaint of "Depression and Anxiety and Thoughts of Harming Self (cutting)", and was assigned an acuity level of "3" by the nurse. Patient #5 was sent to the waiting room area for eight minutes prior to the emergency room nurse performing a triage assessment of the patient on 12/28/12.

Further review of the "Clinical Report-Nurse" notes on 12/28/12 at 19:38 revealed Patient #5 answered "yes" to the following questions: Do you have thoughts of harming or killing yourself? Are you here because you tried to hurt yourself today? " Patient #5 was sent to the waiting room at 19:45 (7:45 p.m.).

Review of the medical record revealed Patient #5 was assessed by a Mental Health Specialist at 20:15 (8:15 p.m.).

Review of the "Clinical Report-Nurse" notes revealed Patient #5 was ambulatory to room on 12/28/12 at 21:29 (9:29 p.m.). Patient #5 was in the waiting room for thirty minutes upon arrival to the emergency room and for one hour and fourteen minutes prior to being brought to a room to be seen by the emergency room physician on 12/28/12.

Review of the "Physician Clinical Report" notes time seen at 20:56 (8:56 p.m.) revealed Patient #5's chief complaint was "Depressed and Suicidal Thoughts...Has been depressed and suicidal thoughts....The patient inflicted self-injury (superficial lacerations to L FA)-left forearm...The symptoms are described as severe...Past history: Depression...(had psyc admit for cutting as teen)...Prior history of suicide attempt..." and was assigned an acuity level of "3". Patient #5 answered "yes" to the following questions: "Have you recently felt down, depressed, or hopeless?", "Have you noticed less interest or pleasure in doing things?", "Do you have thoughts of harming or killing yourself? Are you here because you tried to hurt yourself today?" Patient #5 was sent to the waiting room at 19:45 (7:45 p.m.).

Review of the "Clinical Report-Physician/Mid-Level" date/time seen 12/28/12 at 20:56 (8:56 p.m.) revealed Patient #5's chief complaint was "Depressed and Suicidal Thoughts....Has been depressed and suicidal thoughts...The patient inflicted self-injury (superficial lacerations to L FA)-left forearm...The symptoms are described as severe...Past history: Depression....(had psyc admit for cutting as teen)...Prior history of suicide attempt..." and was assigned an acuity level of "3".

Further review of the medical record revealed Patient #5 was placed in the waiting room from 19:30 through 19:38 for eight minutes, from 19:45 through 20:15 for thirty minutes, and from 20:15 through 21:29 for one hour and fourteen minutes with no 1:1 supervision implemented by an emergency room nurse on 12/28/12.

During an interview on 01/29/13 from 10:40 a.m. through 10:51 a.m., S1CNO and S2ER, Director both confirmed Patient #5 arrived to the emergency department on 12/28/12 at 19:31 with a chief complaint of "Depression and Anxiety and Thoughts of Harming Self (cutting)". S1CNO and S2ER, Director both verified Patient #7 had no triage assessment performed by an emergency room nurse from 19:30 through 19:38 for eight minutes as per policy. S2ER, Director indicated Patient #5 sat in the waiting room for eight minutes without an initial assessment being performed on 12/28/12 as per policy. S2ER, Director verified Patient #5's acuity level was a "3"-Urgent and should have been a level "2" as per policy. S2ER, Director indicated Patient #5 was a threat to herself on 12/28/12. S1CNO and S2ER, Director both verified Patient #5 had no 1:1 supervision protocol implemented for eight minutes, for thirty minutes and/or for one hour and fourteen minutes on 12/28/12 as per policy.

Patient #7's first visit on 12/26/12

Review of the "Clinical Report-Nurse" notes revealed Patient #7 arrived at admitting on 12/26/12 at 01:20 (1:20 a.m.), was triaged at 01:22 (1:22 p.m.) with chief complaints of "Bizarre Behavior" and an acuity level of "3"-Urgent was assigned by the nurse and the patient was placed on 1:1 (one-to-one) with a mental health professional and security at bedside at 01:25 (1:25 a.m.). Further review revealed the emergency room nurse documented, "Patient was unable to be assessed for self harm assessment and a further in depth assessment was planned" at 01:25 on 12/26/12. Patient #7 was to a room at 01:26 (1:26 a.m.), and "left prior to discharge education being provided. (The patient left ER after assessment by ER physician, left prior to signing discharge papers)" on 12/26/12.

Review of the "Mental Health Assessment" dated/timed 12/26/12 at 02:00 (2:00 a.m.) revealed Patient #7's chief complaint reported was he was "...hearing voices. Pt (patient) was very withdrawn....Pt reported he seen an old women standing behind me... " Severe Depression was described as "Pt report feeling sad". Disorientation section answered "yes" to "person, place, time, and situation". Further review revealed the patient had a flat affect documented and "refused to sign a No Harm Contract" at this time with the Mental Health Specialist at 02:00 on 12/26/12.

During an interview on 01/29/13 at 11:20 a.m., S1CNO and S2ER, Director both confirmed Patient #7 arrived to the emergency department on 12/26/12 at 01:20 with a chief complaint of "Bizarre Behavior", with an acuity level of "3"-Urgent, and was placed on 1:1 (one-to-one) with a mental health professional and security at bedside at 01:25 (1:25 a.m.). S2ER, Director verified the "Patient was unable to be assessed for self harm assessment and a further in-depth assessment was planned" by the emergency room nurse at 01:25 on 12/26/12. S2ER, Director confirmed Patient #7's acuity level should have been a level "2" as per policy. S2ER, Director verified Patient #7 refused to sign a "No Harm Contract" with the Mental Health Specialist at 02:00 on 12/26/12. S2ER, Director indicated Patient #7 was a threat to himself on 12/26/12 visit. S2ER, Director denied knowledge of how Patient #7 could leave the ER if on 1:1 supervision on 12/26/12. S2ER, Director further indicated the staff failed to ensure the 1:1 supervision for Patient #7 was maintained on 12/26/12 as per policy.

Patient #7's second visit on 12/28/12

Review of the medical record revealed Patient #7 arrived at admitting on 12/28/12 at 13:23 (1:23 p.m.), was triaged at 13:26 (1:26 p.m.) with chief complaints of "suicidal thoughts and audio hallucinations", was assigned an acuity level of "3"-Urgent by the nurse, was put in a treatment room and had safety precautions initiated with 1:1 (one-to-one) supervision at 13:29 (1:29 p.m.), and discharge/disposition was deferred by S21ER Tech at 10:21 (10:21 a.m.) the next morning, 12/29/12. There was no documentation of what time Patient #7 left the emergency room in the medical record on 12/28/12.

Review of the "Patient Log" for the emergency department revealed Patient #7's arrival time was at 13:23 (1:23 p.m.) and the patient left AMA (against medical advice) at 14:06 (2:06 p.m.) on 12/28/12.

Further review of the medical record revealed there was no documentation Patient #7 had a triage assessment performed by an emergency room nurse from 13:23 through 13:26 for three minutes on 12/28/12. Patient #7 was ambulatory to a room and put on 1:1 supervision at 13:29 on 12/28/12. There was no documented evidence of what time Patient #7's 1:1 supervision was discontinued on 12/28/12.

During an interview on 01/29/13 at 11:20 a.m., S1CNO and S2ER, Director both confirmed Patient #7 arrived to the emergency department on 12/28/12 at 13:23 with a chief complaint of "suicidal thoughts and audio hallucinations". S1CNO and S2ER, Director both verified Patient #7 was placed on 1:1 supervision at 13:29 on 12/28/12. S2ER, Director verified there was no documented evidence Patient #7's 1:1 supervision was discontinued by an emergency room physician on 12/28/12. S2ER, Director confirmed Patient #7's disposition/discharge was AMA (left against medical advice