HospitalInspections.org

Based on record review, and interview, the hospital failed to meet the requirements of the Condition of Participation in Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to inform 1 (#1) of 3 (#1-#3) patients, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care (See findings in A0117).
2) failure to ensure care in a safe setting for Patient #1 during transport from the hospital to another level of care (See findings in A0144).

Based on record review and interview the hospital failed to inform 1 (#1) of 3 (#1-#3) patients, or when appropriate, the patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care.
Findings:

Review of hospital policy #P01-A titled "Patient Rights" dated 10/01/2023, revealed in part: "Purpose: to ensure that each patient /family admitted to hospital is aware of their guaranteed rights and responsibilities. Policy: Each patient/family admitted to the hospital will receive a copy of the Patient Right's policy upon admission."

Review of Patient #1's medical record revealed an admission date of 06/25/2025 and discharge date of 07/23/2025 with diagnoses of anoxic encephalopathy. Continued review failed to reveal evidence that Patient #1 or their representative was notified of their patient rights.

During an interview on 08/12/2025 at 12:15 PM, S13RNS confirmed Patient #1's medical record failed to reveal evidence they or their representative was notified of their patient rights.

Based on record review and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice is evidenced by failure to ensure the safety of Patient #1 during transport from the hospital to another level of care.
Findings:

Review of hospital document titled "Patient Rights and Responsibilities" dated 04/2023, revealed in part: "As a patient, you have the right to: 15. Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect."

Review of document presented as a grievance report log by S6DQ, revealed a complaint date of 07/24/2025 for Patient #1 with a complaint type of "comfort/care" that was documented as "resolved timely" with "telephone conversation" as the mode of conversation with "feedback date" of 08/06/2025 and that a letter was sent.

Review of Patient #1's medical record revealed an admission date of 06/25/2025 and discharge date of 07/23/2025 at 3:00 PM with diagnoses of anoxic encephalopathy and vocal cord dysfunction.

Further review of Patient #1's medical record revealed a "Team Discussion" dated 07/22/2025 (the day before discharge) stating, "Issues related to Patient #1 status include gait ataxia and tremors. Issues of particular significance at this time regarding Patient #1's progress towards rehabilitation goals and treatment plan include tremor, balance, cognition, mobility, self-care, communication and swallow. Safety status: High fall risk; confused. Cognitive Orientation: Person; Place. Cognitive Deficits Observed: delayed responses. He requires supervision and verbal cues during eating, oral hygiene, and bed mobility with 2/2 impulsivity and deficits in motor planning. Barriers to goal achievement: balance deficits, diminished endurance, motor control deficits and cognitive deficits. Patient incontinent of bladder and bowel. Date last assessed 07/21/2025."

Continued review of "Team Discussion" failed to reveal documentation regarding potential transport safety issues related to ataxia, tremors, balance deficits, diminished endurance, motor control deficits and cognitive deficits.

Review of hospital document titled "Review of Clinical Contract Service: 2025 (Company 'A')" revealed Transport Company 'A' was the service used for non-emergent patient transport.

Review of contract agreement between hospital and Transport Company 'A' revealed a signed contract between the hospital and Transport Company 'A' dated January 4th, 2018.

During an interview on 08/12/2025 at 9:48 AM-10:05 AM, S6DQ stated that he spoke with the owner of Transport Company 'A' following a recent complaint when Patient #1 was transported to Hospital 'B'. The patient discharged at approximately 3:00 PM on 07/23/2025 and did not arrive to Hospital 'B' until approximately 7:00 PM. The complainant said Patient #1 arrived with an additional passenger in the front seat, overheated and had fallen forward from the wheelchair into the van hitting his head. S6DQ reported S14RN had also called from Hospital 'B' concerned Patient #1 had not arrived in a timely manner. S6DQ spoke with the owner of Transport Company 'A' who reported the drivers do not use a seat belt within a wheelchair because it is considered a restraint. They use a seatbelt in the van though. A patient who was unbuckled from the van's seatbelt can fall out if having upper body support issues since there is no seatbelt on the patient within the wheelchair. S6DQ indicated case management decides whether a patient needs a stretcher or wheel chair for transport after they speak with physical therapy team. S6DQ confirmed the hospital did not have a policy or procedure for determining transport safety for patients. S6DQ reported the hospital is considering another transport company when the owner of Transport Company 'A' stated the driver, S12SPD, after picking up Patient #1 went to Hospital 'C' to pick up a passenger going in the same direction as Patient #1, causing a 4 hour delay getting Patient #1 to Hospital 'B'. The air conditioning was working but the van was turned off when stopped at Hospital 'C' and overheated the interior of the van. S6DQ verified that it was against policy and protocol for a driver to stop and pick up another passenger when transporting a patient.

During a telephone interview on 08/12/2025 at 12:39 PM, S12SPD reported she had been with Transport Company 'A' for 3 years and remembered Patient #1. S12SPD stated before picking up Patient #1 a previous ride could not be found, but then they called her after picking up Patient #1, and she turned around and picked up the other person from Hospital 'C' who sat in the middle section of the van. S12SPD indicated she did not turn the van off because the other passenger was waiting outside when she pulled up to Hospital 'C'. S12SPD stated the van had no air conditioning problems, but when the door was opened, the heat came in and overheated the van. The transport went well at first but at end of the trip when unloading him his body went out of control, moving on its own and Patient #1 fell out of the wheelchair. During the transport, Patient #1 was attached to a van seatbelt and did not have a seatbelt within the wheel chair.

During a telephone interview on 08/12/2025 at 1:24 PM, S15RN stated she remembered Patient #1. He was weak and could not get up on his own. He sat in a wheel chair and tolerated it okay. S15RN stated that at discharge, transport by stretcher might have been easier on the patient due to his upper body that would 'bob' on its own and that the transport was over an hour long to the Hospital 'B'.

During an interview on 08/12/2025 at 1:30 PM, S8PT stated Patient #1 had severe ataxia and usually discharge planning (case management) and the treating therapist would discuss in team conference the safest mode of transport. S8PT confirmed Patient #1's Team Conference note dated 07/22/2025, did not reveal evidence that the team discussed the safest mode of transport for this patient. S8PT stated it would have been in the patients' best interest to have a discussion in team conference regarding safe transport. S8PT verified if they had known the transport was going to be 4 hours they would have recommended a stretcher. S8PT reported they previously used a van service for appointments and would discuss transport safety between case management and therapist to determine if van versus ambulance was appropriate, but once the facility stopped using that transport company they stopped having the discussion on safe transport. They also provide formal family transport training for discharges home but not for discharges to a facility. S8PT stated she would like to incorporate transport safety into all discharge planning.

Based on record review and interview, the hospital failed to recognize and accurately report factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to recognize an incident of neglect related to the transport by Company 'A' of Patient #1 to another level of care during which the patient fell after traveling over 4 hours to a facility that was approximately 1 hour away in a van that was overheated and contained another passenger.
Findings:

Review of LDH Health Standard Section document titled Self-Reporting Process for Hospitals - Abuse/Neglect revealed in part: "4. Self-Reporting: In the interest of providing information that will indicate the facility's compliance with CMS Regulation 482.13(c) (3) regarding abuse, neglect, and harassment, as well as La R.S. 40:2009.20, the following processes have been developed. It should be noted that a facility's decision to self-report does not eliminate the possibility of an onsite investigation being conducted in response to allegations and/or relevant information received.
Although LA R.S. 40:2009.20 requires a facility to report knowledge of incidents of abuse, within twenty-four hours, to either the local law enforcement agency or LDH (or the Medicaid Fraud Unit as applicable), many facilities find it beneficial to self-report to LDH, even if they have notified law enforcement. It is important to note that contacting law enforcement on behalf or at the request of the patient/complainant (e.g. to press charges, etc.) does not satisfy the statute's intent regarding facility notification.
8: Initial Report (within 24 hours of knowledge): NOTE: Patient-to-patient assaults should be categorized as "Neglect" in relation to "Patient-to-Patient Physical Assault" or "Patient-to-Patient Sexual Assault." From a LDH standpoint, the issue under review is to determine whether the facility failed to take prudent action to prevent, and/or respond to, the (alleged) occurrence. These incidents should be assessed as alleged "Neglect" (i.e. the hospital's failure to act with due diligence). Also indicate what the allegation of neglect involves (i.e. sexual assault, physical assault, elopement, death, or other). The requirement (per statute) is that potential abuse or neglect be reported within 24 hours of knowledge (awareness) of the allegation, suspicion, or occurrence."

Review of hospital policy # A-02-A titled "Abuse, Neglect" last revised 01/01/25, revealed in part: To provide a mechanism for the hospital stff to comply with the hospital's no tolerance policy on abuse, neglect and harassment, and requiring citizens and professionals to report suspected cased of child or dependent adult abuse neglect and/or harassment. To meet al CMS guidelines related to abuse, neglect, and harassment, whether from hospital staff members, patients or hospital visitors. Definition: Neglect is considered a form of abuse and is defined as "failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 5. Protection of patients: All relevant state and local laws related to reporting will be complied with fully including calling law enforcement or state required reporting for any allegation of abuse. 7. Reporting and Response: All allegations of abuse will be reported to the Hospital's Governing Board and as appropriate, to applicable state and federal agencies."

Review of hospital policy # RH-QU-103 titled "Incident Reporting and Management Procedures" last revised 07/01/24, revealed in part: "Policy: To contribute to the promotion of a safe environment for all occupants of the Hospital through the implementation of a hospital-wide incident reporting and review system. Procedure: A staff member who becomes aware of an incident or hazardous condition is responsible for reporting the incident or hazardous condition. Reporting an incident: 1. A staff member who witnesses, discovers, or otherwise becomes aware of an incident will report it by submitting an electronic incident report. Medical Record Documentation: with any incident: an entry will be made in the patient's medical record regarding the objective information related to the incident and any follow-up. Once the incident report is submitted electronically, the director of quality management will review all incident reports and follow-up investigation documentation. External reporting: the legal department, in accordance with applicable regulations is responsible for deciding whether an incident is reportable to an external regulatory and or accrediting body."

During an interview on 08/12/2025 at 9:48 AM-10:05 AM, S6DQ stated that he spoke with the owner of Company 'A' following a recent complaint when Patient #1 was transported to Hospital 'B'. The patient discharged at approximately 3:00 PM on 07/23/2025 and did not arrive to Hospital 'B' until approximately 7:00 PM. The complainant said Patient #1 arrived with an additional passenger in the front seat, overheated and had fallen forward from the wheelchair into the van hitting his head after which Patient #1 was transported to a local emergency department. S6DQ reported S14RN had also called from Hospital 'B' concerned Patient #1 had not arrived in a timely manner.

S6DQ reported the hospital is considering another transport company when the owner of Company 'B' stated the driver, S12SPD, after picking up Patient #1 went to Hospital 'C' to pick up a passenger going in the same direction as Patient #1, causing a 4 hour delay getting Patient #1 to Hospital 'B'. The air conditioning was working but the van was turned off when stopped at Hospital 'C' and overheated the interior of the van.

S6DQ verified that it was against policy and protocol for a driver to stop and pick up another passenger when transporting a patient.

During a telephone interview on 08/12/2025 at 12:39 PM, S12SPD reported she had been with Company 'A' for 3 years and remembered Patient #1. The transport went well at first but at end of the trip when unloading him his body went out of control, moving on its own and Patient #1 fell out of the wheelchair. During the transport, Patient #1 was attached to a van seatbelt and did not have a seatbelt within the wheel chair. S12SPD stated before picking up Patient #1 a previous ride could not be found, but then they called her after picking up Patient #1, and she turned around and picked up the other person from Hospital 'C' who sat in the middle section of the van. S12SPD indicated she did not turn the van off because the other passenger was waiting outside when she pulled up to Hospital 'C'. S12SPD stated the van had no air conditioning problems, but when the door was opened, the heat came in and overheated the van.

Review of document titled "All Incidents Report" dated June 1, 2025 to August 11, 2025 failed to reveal an incident involving Patient #1.

Review of document presented as a complaint report log by S6DQ revealed the following, in part: "Complaint date: July: None. August: None."

Review of hospital documents failed to reveal a self-report submitted to the Louisiana Department of Health, Health Standards Section.

Review of Patient #1's medical record failed to reveal information related to the incident described above.

During an interview on 08/12/2025 at 1:23 PM, S6DQ verified the above findings. S6DQ stated he was investigating the incident but the investigation was ongoing and not completed.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current, a nursing care plan for each patient that reflected the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by failure of the nursing staff to address all of the patients' medical conditions as identified problems on the patients' plan of care for 2 (#1 and #2) of 3 (#1-#3) sampled patient records.

Findings:

Review of Hospital policy # RH-NU-139 titled "Documentation, Nursing", last reviewed 10/01/23, revealed in part: Procedure: A. Each patient shall have a Nursing Plan of Care generated from the information collected during the Admission Assessment. The Nursing Care Plan must be developed by an RN and is a dynamic process that is updated regularly as needed, but minimum weekly.

Patient #1
Review of Patient #1's medical record revealed an admission date of 06/25/2025 and discharge date of 07/23/2025 at 3:00 PM with diagnoses of anoxic encephalopathy and vocal cord dysfunction.

Review of Patient #1's physician orders revealed in part:
06/25/2025: Aspiration precautions.
06/25/2025: Seizure precautions.

Review of Patient #1's Care Plan failed to reveal problems or goals related to aspiration precautions or seizure precautions.

Patient #2
Review of Patient #2's medical record revealed an admission date of 06/11/2025 and discharge date of 08/01/2025 with diagnoses of Traumatic Brain Injury.


Review of Patient #2's physician orders revealed in part:
06/11/2025: Aspiration precautions.
06/11/2025: Seizure precautions.

Review of Patient #2's Care Plan failed to reveal problems or goals related to aspiration precautions or seizure precautions.

During an interview on 08/12/2025 at 12:25 PM, S13RNS confirmed the medical records of Patient #1 and Patient #2 failed to reveal problems or goals related to aspiration precautions or seizure precautions as indicated by the physician orders.

Based on record review and interview, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital as evidenced by failure to reassess Patient #3 per hospital policy following narcotic interventions.
Findings:

Review of Hospital policy # RH-CL-124 titled "Documentation, Nursing", last reviewed 10/01/23, revealed in part: "Purpose: to establish procedures to prevent, assess, diagnose, treat and evaluate the multidimensional aspects of pain. Policy: Procedure: Re-Assessment: iii. Pain will be reassessed 30-60 minutes following a pain reduction intervention and include at minimum pain score and location."

Review of Patient #3's medical record revealed an admission date of 07/24/2025 and a discharge date of 08/11/2025 with a diagnosis of spinal stenosis of lumbar region.

Review of Patient #3's medication administration record revealed the following:
07/24/25: Oxycodone 10 mg administered for pain at 2:37 PM no documentation of pain reassessment within 30-60 minutes as per policy.
07/24/25: Oxycodone 10 mg administered for pain at 8:48 PM no documentation of pain reassessment within 30-60 minutes as per policy.
07/26/25: Oxycodone 10 mg administered for pain at 1:52 AM no documentation of pain reassessment within 30-60 minutes as per policy.
07/27/25: Oxycodone 10 mg administered for pain at 4:45 PM no documentation of pain reassessment within 30-60 minutes as per policy.
08/02/25: Norco 5-325 mg administered for pain at 06:15 AM no documentation of pain reassessment within 30-60 minutes as per policy.
08/05/25: Norco 7.5-325 mg administered for pain at 07:13 PM no documentation of pain reassessment within 30-60 minutes as per policy.
08/08/25: Norco 7.5-325 mg administered for pain at 03:40 AM no documentation of pain reassessment within 30-60 minutes as per policy.
08/11/25: Norco 7.5-325 mg administered for pain at 06:26 AM no documentation of pain reassessment within 30-60 minutes as per policy.

In an interview on 08-11-2025 at 2:35 PM, S13RNS confirmed the above findings and stated Patient #3's medical record does not reveal evidence of nursing reassessment following narcotic interventions per hospital policy.

Based on record review and interview the hospital failed to assess its discharge planning process on a regular basis as evidenced by failure to complete an ongoing, periodic review of a representative sample of discharge plans to ensure that the plans are responsive to the patient post-discharge needs.
Findings:

Review of hospital's policy #RH-CM-102 titled, "Discharge Planning", last revised 07/01/2024, revealed in part: "Scope: To provide a framework around providing a safe and reasonable discharge plan for each patient."

Review of hospital's policy #RH-QU-106 titled, Quality Assessment and Performance Improvement Plan" last revised on 01/01/2023, revealed in part: The QAPI program addresses all aspects of services provided to ensure patients receive sage, timely, effective, efficient, equitable and patient-centered care. The Hospital aims to provide high quality care in all aspects awhile respecting the patients' rights and wishes."

Review of hospital's documents provided by S1ADM and S6DQ failed to reveal evidence of an ongoing, periodic review of a representative sample of discharge plans including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs.

During an interview on 08/11/2025 at 4:01 PM, S6DQ confirmed the hospital had not implemented an ongoing, periodic review of a representative sample of discharge plans to assess its discharge planning process.

Based on record review and interview, the hospital failed to ensure written policies and procedures for transferring patients under its care to the appropriate level of care as needed to meet the needs of the patient and provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care.
Findings:

Review of hospital's documents provided by S1ADM and S6DQ failed to reveal evidence of written policies and procedures and annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care.

During an interview on 08/11/2025 at 4:01 PM, S6DQ confirmed the hospital had not implemented policies and procedures for transferring patients under its care to the appropriate level of care as needed to meet the needs of the patient and provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care.