Ochsner Lafayette General Medical Center

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 44763 Based on observation and interview, the infection control officer failed to ensure the hospital’s system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by the hospital failing to maintain a sanitary environment. Findings: Tour of the emergency department on 01/27/2026 at 1:40 PM - 2:19 PM accompanied by SF3PIC and SF6EDM revealed gray, fuzzy matter observed to the back of the cardiac monitor in room ‘Fa’. Observation of room ‘Fb’ revealed dried mud/dirt on the floor near the drain and a used diaper near the stretcher bed and wheelchair. In an interview during the observation, SF6EDM confirmed the above stated findings.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to ensure the appropriate transfer of psychiatric patients, placed on a Physician’s Emergency Certificate [PEC], who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This deficient practice was evidenced by the hospital’s failure to ensure appropriate supervision during transfer for 1 (#5) of 5 (#2, #3, #4, #5, #8) reviewed psychiatric patients with a PEC in need of acute inpatient psychiatric care from a total sample of 20. The hospital allowed Company ‘A’ to transport the patient using a single driver and the patient eloped when arriving at the receiving hospital (see findings tag A-2409).”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure the appropriate transfer of psychiatric patients, placed on a Physician’s Emergency Certificate [PEC], who were in need of acute inpatient psychiatric services of which the sending hospital was unable to provide at the time of transfer. This deficient practice was evidenced by the hospital’s failure to ensure appropriate supervision during transfer for 1 (#5) of 5 (#2, #3, #4, #5, #8) reviewed psychiatric patients with a PEC in need of acute inpatient psychiatric care from a total sample of 20. The hospital allowed Company ‘A’ to transport the patient using a single driver and the patient eloped when arriving at the receiving hospital. Findings: Review of the hospital’s policy titled “Emergent Patient Transfer Facilitation”, approval date 02/21/2025, revealed in part, “F. Transfer Procedure for Emergent Patients: 12.) The hospital will assist the referring physician/APC [Advanced Practice Clinician] in obtaining the appropriate personnel and equipment for the transfer of the patient. A record will be maintained of the physician order and the manner by which the order was fulfilled.” Review of Patient #5’s emergency department (ED) record revealed Patient #5 presented to the ED on 05/26/2025 at 12:47 PM with a chief complaint of abdominal pain/ingestion. Review of the provider’s note dated 05/26/2025 by S5MD revealed in part, “Patient is a [stated age] female with a past medical history of depression and anxiety presenting to the ED after taking a handful of 500 mg [milligrams] Tylenol at 1200. Patient reports she had a fight with her husband last night and states she started drinking after. This morning she reports ‘I was trying to take my vitamins but accidentally took a handful of Tylenol.’ She estimates that she took about 20. She denies SI [suicidal ideation].” Further review of the document revealed, “After an argument with her husband and chart showing history of depression and anxiety, it is difficult to fathom how she would take a handful of Tylenol mistaking it for her vitamins. Out of an abundance of caution, she is placed on a psychiatric hold until she is cleared by a psychiatrist.” “Medically cleared for psychiatry placement: 05/26/2025 5:09 PM.” “Clinical Impression: Final Diagnoses: Tylenol overdose.” Review of the PEC dated 05/26/2026 revealed Patient #5 was dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of the Transfer Certificate dated 05/26/2025 revealed in part, Patient #5 was transported to Hospital ‘B’ by Company ‘A’. Further review of the document revealed “The patient will be transferred via Company ‘A’ - car by qualified personnel and transportation equipment as required, including the use of necessary and medically appropriate life support measures.” Review of the Louisiana Department of Health (LDH) Hospital / Licensed Provider Abuse / Neglect Initial Report from Hospital ‘B’ revealed in part, “Patient #5 was accepted for acute inpatient treatment from Lafayette General Medical Center under a PEC admission. At approximately 2229 hours, a Company ‘A’ vehicle arrived at the facility. Hospital staff were notified of the arrival, and the front entrance door was promptly opened and secured as preparations were made to receive the patient. The Company ‘A’ driver was observed retrieving the patient’s personal belongings. At the same time, the driver opened the transport vehicle door, allowing Patient #5 to exit. While assisting the patient from the vehicle, the driver was seen holding the patient by the arm. The patient suddenly broke free from the driver’s grasp and immediately fled in a northeastern direction toward [stated street]. Hospital staff were observed exiting the unit in an attempt to retrieve the patient; however, the attempt was unsuccessful. The [named] police department was promptly notified and provided with information regarding the elopement.” In an interview on 06/18/2025 at 12:26 PM S3EDD stated he spoke to the supervisor of Company ‘A’. S3EDD stated the supervisor told him that he spoke to the driver that transported Patient #5. S3EDD stated the driver reported to the supervisor that Patient #5 eloped when they arrived at Hospital ‘B’. Review of the hospital’s services agreement with Company ‘A’ revealed “Additional Company ‘A’ Transportation Policies, Procedures and Protocols” attached. Further review of the “Additional Company ‘A’ Transportation Policies, Procedures and Protocols revealed in part, “B. Procedures: 3.) The call will be dispatched to the Company Transport Team located in the closest proximity to the requesting facility. a.) Company Transport Teams consist of two staff members trained according to the Company Driver Selection, Training and Certification Standards. Both Team Members are capable of driving the Company’s vehicle (driver) and rendering assistance as needed when appropriate (attendant).” “Procedures at Receiving Facility: 16.) Once inside the facility, the staff must sign the trip sheet verifying patient and valuables delivery.” Review of Company ‘A’ Trip Sheet revealed there was not a signature from the receiving hospital verifying patient and valuables delivery. In an interview on 06/18/2025 at 10:56 AM S3EDD confirmed in general Company ‘A’ has one employee, the driver when transporting psychiatric patients. In an interview on 06/23/2025 at 9:05 AM S6RN stated she did not recall Patient #5. S6RN stated when Company ‘A’ arrives to the hospital to transport a patient, Company ‘A’ has one employee. S6RN stated just the driver. S6RN confirmed she has never seen Company ‘A’ with 2 people. S6RN confirmed it’s always one person and it’s the driver. In an interview on 06/18/2025 at 2:10 PM S2DRR verified the hospital’s service agreement with Company ‘A’ states Company ‘A’ transport teams consist of two staff members.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to include patient name in the Emergency Department (ED) Transfer log (see findings tag A-2405) and 2.) the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 1 (#7) of 20 (#1-#20) sampled patients (see findings tag A-2411).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment,,was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to include patient name in the Emergency Department (ED) Transfer Request log. Findings: Review of the hospital’s policy titled “Admission, Discharge and Transfer Guidelines for the Emergency Department”, approval date 09/14/2023, revealed in part, “IV. Policy Implementation: 7.) A registration log containing the patient’s name, date and time of arrival, chief complaint, and disposition will be maintained on paper or electronically.” Review of the hospital’s ED Transfer Request log failed to reveal any patient names. In an interview on 03/06/2025 at 8:52 AM S2PFCM verified the way the system pulls the reports, the patient name is not included in this report. S2PFCM verified the system pulls the MRN [medical record number] and then by using the MRN the staff can look up the patient name within the EMR [electronic medical record] system.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 1 (#7) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “Emergent Patient Transfer Facilitation”, approval date 02/21/2025, revealed in part, III. Policy Statements: C. Under EMTALA, a hospital is obligated to accept a Transfer of a patient from another facility when: i. The patient is in emergent status (i.e., has an Emergency Medical Condition). ii. The referring hospital does not have the medical capability or capacity to provide the service. iii. The benefit of the Transfer outweighs the risk of Transfer as certified by the requesting physician. iv. The destination facility has the medical capability to provide the requested services. v. The destination facility has the available capacity (beds, staff, and equipment) at the time of the request to provide appropriate care to the patient.” Review of Patient #7’s emergency department (ED) record from hospital ‘A’ revealed Patient #7 presented to the ED on 03/01/2025 at 8:20 AM. Review of the provider note revealed in part, patient states he was using a chainsaw to cut a tree limb when he accidentally scraped his left great toe with a chainsaw. Thankfully it was just a superficial injury and did not bleed much. He has minimal pain. He states he has not had any other illness denies fevers, chills, sweats, cough, cold rhinorrhea, sore throat, nausea, vomiting, or diarrhea. Further review of the document revealed in part, 03/01/2025 2:00 PM: I spoke with the transfer center at Lafayette General and was told that S3DO orthopedic surgery would be called to discuss the transfer verses having the patient follow-up in his clinic as we do not have orthopedic surgery on-call. I received a call back from S3DO who disputed the transfer and said that the patient should follow-up with an orthopedic surgeon in Opelousas. I explained to him that we do not have an orthopedic surgeon to send the patient to explaining that we do not have orthopedic surgery on-call. I explained in great detail that we have spine surgery on-call with [named] explaining his story and why he takes spine call almost every day and rotates through orthopedic surgery call but is not on-call for orthopedics. He verbalized understanding and said that he would talk to the transfer center. We then received a call from the transfer center stating that the transfer is refused. I called hospital ‘B’ ER [emergency room] and discussed the case explaining I don’t have ortho [orthopedics] on call along with my exam, the xray and my findings during the washout and loose closure. He called on call ortho then called me back stating if patient is NV [neurovascularly] intact with nml [normal] cap [capillary] refill, receives systemic abx [antibiotics] and I’m comfortable with outpt [outpatient] f/u [follow-up], he will see patient in office Monday. I explained ancef 1 gram IM [intramuscular] had been given. I agree with this plan. No further recs from hospital ‘B’. Patient #7 was discharged home on 03/01/2025 at 12:56 PM from hospital ‘A’. Review of the Patient Flow Center documentation from Ochsner Lafayette General Medical Center revealed in part, 03/01/2025 11:57 AM: Presented patient for transfer and S3DO states he called and spoke to the referring provider who confirmed they have orthopedic surgeon [named] on call but he is only on call for spine not general ortho. S3DO called S4MD and they both discussed case and declined patient because referring has ortho MD on call that can manage the toe or have patient follow up with him outpatient. Patient declined to OLG [Ochsner Lafayette General]. Further review of the documentation failed to reveal any documentation the patient was refused transfer due to the facility being at capacity. In an interview on 03/06/2025 at 11:38 AM S2PFCM verified Patient #7 was declined due to the referring hospital having the service available. S2PFCM stated orthopedic surgeon, S3DO recommended Patient #7 be seen by the referring hospital’s on-call doctor or to see him outpatient for a big toe injury.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to provide a nursing care plan per hospital policy. This deficient practice was evidenced by failure of the RN to review the nursing care plan a minimum of every 24 hours for 2 (#1, #3) of 3 (#1, #2, #3) patients reviewed. Findings: Review of the hospital’s policy titled “Documentation of Outcomes and the Nursing Plan of Care” effective date 02/07/2022, revealed in part: 2.) The Care Plan should be reviewed daily and updated as needed based on patient response to interventions or status changes. Any unresolved problems should be addressed at discharge. Review of the hospital’s policy titled “Assessment and Reassessment (Hospitalized Patients)” effective date 12/13/2021, revealed in part: G. The patient is reassessed as necessary based on his/her plan of care for changes in his/her condition. An RN must reassess the patient a minimum of every 24 hours. Patient #1 Review of Patient #1’s medical record revealed an admission date of 06/01/2024 and a discharge date of 06/03/2024. Review of Patient #1’s nursing care plan revealed no documentation that the RN reviewed Patient #1’s nursing care plan on 06/02/2024. In an interview on 06/20/2024 at 2:36 p.m. S2RiskMg and S3RiskMg verified there was no documentation that the RN reviewed Patient #1’s nursing care plan on 06/02/2024. Patient #3 Review of Patient #3’s medical record revealed an admission date of 05/19/2024 and was a current patient on 06/20/2024. Review of Patient #3’s nursing care plan revealed no documentation that the RN reviewed Patient #3’s nursing care plan on the following dates: 05/26/2024 - 05/28/2024; 05/30/2024 - 06/04/2024; 06/06/2024; 06/12/2024 - 06/14/2024; and 06/16/2024. In an interview on 06/20/2024 at 5:10 p.m. S3RiskMg verified there was no documentation that the RN reviewed Patient #3’s nursing care plan on the above stated dates. In an interview on 06/20/2024 at 5:30 p.m. S1DirReg verified the expectation of the RN is to review nursing care plans every 24 hours.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by: 1.) the staff failing to use emergency medical equipment during a medical emergency for 1 (#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3; and 2.) the nurse failing to stay with the patient during a medical emergency until emergency medical service arrived for 1(#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3. Findings: 1.) The staff failing to use emergency medical equipment during a medical emergency for 1 (#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3. Review of the hospital’s policy titled “BHU-Medical Emergency and Emergency Bag”, effective date 03/27/2023, revealed in part, In the event of a medical emergency requiring cardiopulmonary resuscitation, the BHU staff will follow Basic Life Support protocol, and begin CPR on all patients unless the patient is identified as having a “Do Not Resuscitate” order executed through the Advance Directive. Staff will bring the Emergency Medical Bag, AED, Oxygen tank with ambu-bag, and portable suction to the location of the medical emergency. Available staff are to contact Emergency Medical Service (EMS) for emergency transport. Staff continues CPR until EMS arrive to assume control of emergency measures. Review of the self-report to State Office dated 03/05/2024 revealed in part, On 03/05/2024 at 2:15 p.m. S6MHT found Patient #1 in patient’s room closet with a sheet wrapped around his neck hanging from the fire sprinkler. The sheet was removed from Patient #1’s neck, CPR started, and EMS was called. EMS arrived, took over care, and pronounced Patient #1 deceased. Review of the video surveillance footage on 03/13/2024 at 2:46 p.m. revealed the following: On 03/05/2024 at 2:15 p.m. S6MHT looks into Patient #1’s room, starts to go to the next room and then returns and enters Patient #1’s room. At 2:16 p.m. S6MHT exits Patient #1’s room calling for help. S9LCSW is first to enter Patient #1’s room, followed by other staff members. S10LPN is with them, walking, and also enters Patient #1’s room. At 2:17 p.m. S10LPN exits Patient #1’s room stands outside the door for approximately 15 seconds, then returns to Patient #1’s room for several seconds, and then exits again and retrieves a vital sign machine. At 2:18 p.m. S11RN was seen walking to Patient #1’s room and then enters the room. At 2:19 p.m. S6MHT leaves Patient #1’s room and returns with the emergency bag. At 2:23 p.m. S11RN exits Patient #1’s room, stopping in the hallway, and then returns to nurse station. At 2:25 p.m. S10LPN exits Patient #1’s room. At 2:27 p.m. Law Enforcement Officers enter through the intake doorway on way to Patient #1’s room (which is across the hallway). At 2:28 p.m. EMS personnel arrive. 2:30 p.m. S11RN leaves the nurse’s station and walks to Patient #1’s room and speaks to Law Enforcement Officer. EMS exits Patient #1’s room with an empty stretcher. At 2:33 p.m. S11RN returns to nurse’s station. Observation on 03/13/2024 at 4:01 p.m. - 4:45 p.m. of the BHU revealed the emergency medical bag, 2 oxygen tanks, and ambu-bags were present in the physician’s office. Further observation of the emergency medical bag revealed the AED inside the bag. In an interview during the observation, S5AVPN verified the staff brought the emergency medical bag and ambu-bag to Patient #1’s room during the medical emergency. S5AVPN verified the emergency medical bag was not opened by the staff during the medical emergency due to the locks on the bag still being intact. S5AVPN verified the AED was not used during Patient #1’s medical emergency due to the AED being inside of the emergency medical bag. S5AVPN verified the emergency medical bag should have been opened and the AED should have been connected to Patient #1 during the medical emergency. In an interview on 03/14/2024 at 9:30 a.m. S5AVPN verified the ambu-bag was used during Patient #1’s medical emergency using room air. S5AVPN verified the staff did not bring an oxygen tank to Patient #1’s room to be used with the ambu-bag. S5AVPN verified the ambu-bag should have been connected to the oxygen tank during Patient #1’s medical emergency. 2.) The nurse failing to stay with the patient during a medical emergency until emergency medical service arrived for 1(#1) of 1 (#1) patients reviewed that had a medical emergency of a total sample of 3. Review of the hospital’s policy titled “BHU-Medical Emergency and Emergency Bag”, effective date 03/27/2023, revealed in part, Charge nurse will lead emergency measures and stay with the patient until ambulance crew arrives to take over care. Review of the self-report to State Office dated 03/05/2024 revealed in part, On 03/05/2024 at 2:15 p.m. S6MHT found Patient #1 in patient’s room closet with a sheet wrapped around his neck hanging from the fire sprinkler. The sheet was removed from Patient #1’s neck, CPR started, and EMS was called. EMS arrived, took over care, and pronounced Patient #1 deceased. Review of the video surveillance footage on 03/13/2024 at 2:46 p.m. revealed the following: On 03/05/2024 at 2:15 p.m. S6MHT looks into Patient #1’s room, starts to go to the next room and then returns and enters Patient #1’s room. At 2:16 p.m. S6MHT exits Patient #1’s room calling for help. S9LCSW is first to enter Patient #1’s room, followed by other staff members. S10LPN is with them, walking, and also enters Patient #1’s room. At 2:17 p.m. S10LPN exits Patient #1’s room stands outside the door for approximately 15 seconds, then returns to Patient #1’s room for several seconds, and then exits again and retrieves a vital sign machine. At 2:18 p.m. S11RN was seen walking to Patient #1’s room and then enters the room. At 2:19 p.m. S6MHT leaves Patient #1’s room and returns with the emergency bag. At 2:23 p.m. S11RN exits Patient #1’s room, stopping in the hallway, and then returns to nurse station. At 2:25 p.m. S10LPN exits Patient #1’s room. At 2:27 p.m. Law Enforcement Officers enter through the intake doorway on way to Patient #1’s room (which is across the hallway). At 2:28 p.m. EMS personnel arrive. 2:30 p.m. S11RN leaves the nurse’s station and walks to Patient #1’s room and speaks to Law Enforcement Officer. EMS exits Patient #1’s room with an empty stretcher. At 2:33 p.m. S11RN returns to nurse’s station. In an interview on 03/14/2024 at 8:44 a.m. S5AVPN verified the RN did not stay continuously with Patient #1 until EMS arrived during the medical emergency.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 14442 Based on record reviews and interviews, the hospital failed to ensure the patient right to receive care in a safe setting. This deficient practice was evidenced by failing to ensure a first year surgical resident was under direct supervision by the supervising physician during an incision and drainage procedure that resulted in severe pain for 1 (#1) of 3 (#1-#3) sampled patients. Findings: Review of the hospital Graduate Medical Education: Resident Supervision policy revealed, in part: I. Purpose: To ensure that sponsored residency programs provide appropriate supervision to residents in accordance with the ACGME Institutional and Common Program Requirements. III. Policy Statements. A. Each sponsored, accredited residency program will develop criteria and procedures which specify that residents are provided with progressively increasing responsibility for patient care according to their level of education, ability, and experience. These criteria must specify the extent to which residents may undertake patient without direct supervision. The program must use the following classifications of supervision: 1. Direct Supervision: the supervising physician is physically present with the resident and patient. B. PGY 1-residents should be supervised either directly or indirectly with direct supervision immediately available. PGY-1 residents should be supervised directly until the resident has demonstrated sufficient competence to progress being supervised indirectly with direct supervision available. Review of the hospital residency program General Surgery Levels of Care documentation revealed, in part: Supervision: Direct-the supervising physician is physically present with the resident and patient. Further review revealed, in part, for drain abscess procedure a PGY-1 resident required direct supervision by the supervising physician. Review of Patient #1’s medical record revealed an admit date of 11/09/2023. Patient #1 had the diagnosis of left groin abscess and scheduled for bedside incision and drainage procedure. Review of Patient #1’s medical record revealed the patient had a bedside incision and drainage done on 11/10/2023 by S3MD, PGY-1 surgical resident. There was no evidence S3MD, PGY-1 had direct supervision by a supervising physician during the procedure. Review of Patient #1’s nurses notes revealed pain level at “10” during the procedure. Review of the hospital Pain Assessment policy revealed, in part: Pain intensity will be measured using the 0 - 10 scale or Wong-Baker Faces. The pain scale includes numbers and a description of how to describe each patient’s pain. i.e., 7 - 10= severe pain. Further review revealed a Universal Pain Assessment Tool with pain level 10= worst pain possible. In an interview on 12/28/2023 at 11:07 a.m., S4RN confirmed she was the Charge Nurse on 11/10/2023 when Patient #1 had an incision and drainage of left groin abscess done at bedside. S4RN confirmed the incision and drainage was performed by S3MD, PGY-1 surgical resident. S4RN confirmed she was informed by S5RN of the patient’s severe pain and spoke with S3MD, PGY-1 resident about stopping the procedure due to the inability to adequately control the patient’s pain at bedside. S4RN confirmed Patient #1 was in severe pain. S4RN confirmed S3MD, PGY-1 surgical resident did not have a supervising physician physically present with the resident and patient during the procedure. In an interview on 12/28/2023 at 12:56 p.m., S1VP Regional CNO confirmed the hospital Graduate Medical Education: Resident Supervision policy for incision and drainage procedure (drain abscess) required PGY-1 surgical residents to be under direct supervision with the supervising physician physically present with the resident and patient during the procedure. S1VP Regional CNO confirmed this was not done for Patient #1’s left groin abscess incision and drainage procedure on 11/10/2023. In an interview on 01/03/2024 at 9:28 a.m., S5RN confirmed she was Patient #1’s nurse on 11/10/2023 when Patient #1 had an incision and drainage of left groin abscess done at bedside. S5RN confirmed the incision and drainage was performed by S3MD, PGY-1 surgical resident. S5RN confirmed Patient #1 was in extreme pain and wanted to stop the procedure and have the procedure done in surgery and under sedation. S5RN confirmed she informed S4RN, Charge Nurse who intervened and the procedure was stopped. S5RN confirmed S3MD, PGY-1 surgical resident did not have a supervising physician physically present with the resident and patient during the procedure.”