HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet requirements for the Conditon of Participation for Patient Rights. The deficient practice is evidenced by failure to maintain one to one observation level for 2 (#1, #4) of 4 (#1, #2, #3, #4) sampled patients resulting in the elopement of one patient (#1) (See Tag A0144).

Based on record review and interview, the hospital failed to ensure one to one observation level on a PEC patient for 2 (#1, #4) of 4 (#1, #2, #3, #4) sampled patients.

Findings:

Review of the hospital policy, "PEC/CEC- Provisional Psychiatric Care." created on 09/2008 and the latest reviewed on 05/2024 revealed the following:
"Objective/s:
To ensure that every individual in need of care and treatment related to psychology and/or psychiatric disorders receives care in prompt, safe, and calm environment.
To provide guidelines for appropriate treatment and placement of patients admitted by a Physician's Emergency Certificate (PEC)/Coroner's Emergency Certificate (CEC) while promoting patient safety.
Process or Procedures:
F. All PEC/CEC patients are placed on one to one (1:1) observation with a de-escalation-trained, CSBHS associate."

Review of the "Sitter Education Checklist for 1:1 Monitoring of Patients," revealed in part:
"Observe the patient at ALL TIMES if you need a break notify the nurse.
Maintain visual observance of the patient at all times. This includes the use of restroom facilities.
Never leave the patient.
Observe the patient at all times including him/her in the bathroom.
Notify the patient's nurse if you require a break."

Patient #1
Record review of Patient #1's medical record revealed the following, in part:
Patient #1 presented to the emergency department (ED) on 06/17/2025 at 4:59 PM with a chief complaint of suicide attempt. Patient arrived to ED from home with complaint of suicide attempt. EMS reported patient states she took 50 HCTZ. Patient states she was going to but washed them down the sink. EMS also reports multiple lacerations to left arm from self-inflicted razor cuts. Patient AAO x 3 and denies any SI or HI but just states she is depressed. Patient states she has a family history of bipolar. No complaints of chest pain or SOB. Respirations even and unlabored. NAD noted.

The patient was evaluated by a physician and placed under a Physician's Emergency Certificate (PEC). Review of Patient #1's PEC dated 06/17/2025, exam time 5:10 PM, signed 5:20 PM by MD reveled, in part, "Patient #1 PEC exam included mental illness or substance abuse, possible suicide attempt with HCTZ, currently depressed, dangerous to self, multiple superficial lacerations to left forearm." Further review of the record revealed Patient #1 eloped from the hospital after having been left unattended in the restroom.

Review of the hospital's self-report to Louisiana Department of Health revealed, in part:
Surveillance/Video- Patient #1 was escorted to the bathroom by S1RN, Patient #1 exited, spoke to S1RN and asked for a medication. S1RN left the Patient in the bathroom and went to ask for the order at 06:54:11 PM. S1RN returned to Line-of Sight Monitoring at 07:00:04 PM. At 07:02:15 PM, S1RN checks the bathroom and realizes Patient #1 has fled. S1RN notifies all parties and a search ensues. Video Surveillance identifies the patient exiting through the vending area, walking across the ER lobby, exiting through the main ER Entrance then running across the street. Last image was of Patient #1 across the street.

Investigation results- We were not able to provide a 1:1 sitter and monitoring for this PEC patient at that time of the elopement secondary to current census and staffing. Nursing Services was preparing to send a sitter from our request. They had not yet arrived when the elopement occurred.

Review of the hospital's House Supervisor's Daily Duties (updated 06/26/2025) revealed, in part, "If a patient is placed on a PEC or CEC, immediately review staffing in all departments including nurse externs and shift resources to provide 1:1 observation. Instruct nursing staff to remain with patient until a sitter arrives ..."

Review of the hospital's occurrence report for this incident revealed the following, in part:
Date of event 06/17/2025 at 7:05 PM.
PEC patient (Patient #1) eloped.

Interview on 07/22/2025 at 11:35 AM, S2QM reported, the facility's PEC/CEC policies state that all PEC/CEC patients are placed on 1:1 observation with a de-escalation-trained associate. S2QM reported that a sitter never arrived prior to Patient #1's elopement. S2QM also reported the staff did not maintain 1:1 observations per the facility's policy.

Patient #4
Record review of Patient #4's medical record revealed the following, in part:
Patient #4 was admitted to the ER on 07/23/2025 at 4:36 AM with a chief complaint of severe paranoia. Patient reports he was supposed to go to a Behavioral Health facility yesterday but he could not get a ride. Patient reports he feels like people are following him and trying to get him. Patient reports he did use meth and alcohol today. Patient denies SI/HI.

Patient #4 was evaluated by the physician and placed under a Physician's Emergency Certificate (PEC) at 5:00 AM on 07/23/2025. The physician documented, "flight of ideas. He repeats the statement over and over, he has suicidal ideations without plan, lots of social issues. Recent separation. Using Meth and alcohol. Not sleeping. Paranoid. Patient #4 is currently suicidal. "

Observation in the emergency department on 07/23/2025 at 10:05 AM, accompanied by S3ERCD, revealed Patient #4 was in his room lying on stretcher. The assigned sitter for 1:1 observation was not present, an empty chair was at the door to the room. S3ERCD was with surveyor and also reported the sitter was not present. S2ERCD asked the two nurses (S4RN and S5RN) where the sitter was and they both said they did not know. S3ERCD asked the two nurses if the sitter notified them and they both said "NO."

Interview on 07/23/2025 at 10:10 AM, S3ERCD verified there was not a sitter present for 1:1 observation for Patient #4 and the emergency department staff were not following the hospital policy for patients under a PEC.

Based on record review and interview, the hospital failed to recognize deficiencies related to patient safety. The deficient practice is evidenced by failure to recognize neglect after the elopement of a patient from the emergency department.
Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding §2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Pursuant to LA R.S. 40:2009.20 facilities/health care workers shall report abuse/neglect allegations within 24 hours of receiving knowledge of the allegation to the Louisiana Department of Health (LDH). For the purposes of this process Health Standards, the Louisiana Department of Health (LDH) Legal Services Division, and the Office of the Attorney General have interpreted this to mean that the 24-hour time frame begins as soon as any employee or contract worker at the facility (including physicians) becomes aware that an incident of abuse/neglect has been alleged, witnessed, or is suspected, regardless of the source of information and regardless of the existence or lack of supporting evidence.

Review of the document, "Self Reporting Process for Hospitals- Abuse/Neglect," revised 12/01/21, revealed in part, "
11. Facility Investigation (Administrative Review) and Final Investigative Report
The Final Investigative Report should be submitted to HSS as soon as it is concluded, but within five working days of submitting the initial report. The hospital may submit additional information (such as completion of staff education, etc.) after the Final Investigative Report has been submitted. An addendum of this nature should clearly identify the hospital, the five-digit ID number HSS assigned to the event, the date of the incident, and must include enough information to link the document to the appropriate incident/event. Final reports and attached documents should be submitted via email, whenever possible, and should be encrypted as they will contain Protected Health Information (PHI).

The final report should provide evidence that the facility conducted a thorough investigation and took measures to prevent future incidents. Issues with hospital systems, policies and procedures, regular practices that contributed to the event should be scrutinized and identified in the report. Specific actions taken in regard to systems and personnel involved should be documented (e.g., education, disciplinary actions, policy revisions, etc.). The final report must indicate whether the allegations were substantiated or not (it is acceptable to state that allegations were unable to be substantiated due to lack of evidence).

Review of the "Sitter Education Checklist for 1:1 Monitoring of Patients," revealed in part:
Observe the patient at ALL TIMES if you need a break notify the nurse.
Maintain visual observance of the patient at all times. This includes the use of restroom facilities.
Never leave the patient.
Observe the patient at all times including him/her in the bathroom.
Notify the patient's nurse if you require a break.

Review of the hospital's House Supervisor's Daily Duties (updated 06/26/2025) revealed, in part, "If a patient is placed on a PEC or CEC, immediately review staffing in all departments including nurse externs and shift resources to provide 1:1 observation. Instruct nursing staff to remain with patient until a sitter arrives ..."

Patient #1
Record review of Patient #1's medical record revealed the following, in part:
Patient #1 presented to the emergency department (ED) on 06/17/2025 at 4:59 PM with a chief complaint of suicide attempt. Patient arrived to ED from home with complaint of suicide attempt. EMS reported patient states she took 50 HCTZ. Patient states she was going to, but washed them down the sink. EMS also reports multiple lacerations to left arm from self-inflicted razor cuts. Patient AAO x 3 and denies any SI or HI but just states she is depressed. Patient states she has a family history of bipolar. No complaints of chest pain or SOB. Respirations even and unlabored. NAD noted.

The patient was evaluated by a physician and placed under a Physician's Emergency Certificate (PEC). Review of Patient #1's PEC dated 06/17/2025, exam time 5:10 PM, signed 5:20 PM by MD reveled, in part, "Patient #1 PEC exam included mental illness or substance abuse, possible suicide attempt with HCTZ, currently depressed, dangerous to self, multiple superficial lacerations to left forearm." Further review of the record revealed Patient #1 eloped from the hospital after having been left unattended in the restroom.

Review of the hospital's self-report to Louisiana Department of Health revealed, in part:
Surveillance/Video- Patient #1 was escorted to the bathroom by S1RN, Patient #1 exited, spoke to S1RN and asked for a medication. S1RN left the Patient in the bathroom and went to ask for the order at 06:54:11 PM. S1RN returned to Line-of Sight Monitoring at 07:00:04 PM. At 07:02:15 PM, S1RN checks the bathroom and realizes Patient #1 has fled. S1RN notifies all parties and a search ensues. Video Surveillance identifies the patient exiting through the vending area, walking across the ER lobby, exiting through the main ER Entrance then running across the street. Last image was of Patient #1 across the street.
Investigation results- (Was the allegation substantiated, unsubstantiated, or unable to substantiate due to lack of evidence?) We were not able to provide a 1:1 sitter and monitoring for this PEC patient at that time of the elopement secondary to current census and staffing. Nursing Services was preparing to send a sitter from our request. They had not yet arrived when the elopement occurred.

Interview on 07/22/2025 at 11:35 AM, S2QM reported, the facility's PEC/CEC policies state that all PEC/CEC patients are placed on 1:1 observation with a de-escalation-trained associate. S2QM reported that a sitter never arrived prior to Patient #1 elopement. S2QM also reported the staff did not maintain 1:1 observations per the facility's policy.