Rapides Regional Medical Center

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 53243 Based on record review and interview, the hospital failed to obtain signed consent for treatment and patient rights for 1 (#2 ) of 3 sample patients reviewed for signed consents upon hospital admissions from the emergency department. Findings: A review of hospital policy, “Consent, Informed,” last reviewed date 07/25 revealed in part: “Upon admission, all patients sign a “Conditions of Admission and Authorization for Medical Treatment” form. “ A review of Patient #2’s medical record revealed Patient #2 presented to hospital’s emergency department on 08/05/2026 at 4:17 PM. Further review of Patient #2’s medical record revealed on 08/05/2026 at 5:38 PM, patient was admitted as an inpatient. Interview on 08/24/2026 at 2:10 PM during review of Patient #2’s electronic medical record with S3ERD, she stated she was unable to locate the signed consent for treatment and review of patient rights in the electronic medical record. Interview on 08/25/2026 at 8:38 AM, S2DRM confirmed no patient rights or informed consent for treatment were signed. Interview on 08/25/2026 at 11:13 AM, S1VPQ confirmed patient consent for treatment and patient rights are in one document and a signature should be obtained from patient prior to receiving treatment. She stated at this time we cannot locate that document in Patient #2’s medical record.”

“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: 48051 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals to comply with 42 CFR §489.24, Special Responsibilities of Medicare Hospitals in emergency cases as evidenced by the failure to ensure the physician certifications and patient transfer consents were completed prior to the transfer of a patient in 10 (#1, #2, #3, #7, #8, #9, #11, #12, #13, #14) of 14 medical records reviewed for an appropriate transfer (See Tag A2409).”

“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: 48051 Based on record review and interview, the hospital failed to ensure the physician certification and the consent for transfer were completed prior to the patient being transferred in 10 (#1, #2, #3, #7, #8, #9, #11, #12, #13, #14) of 14 medical records reviewed for an appropriate transfer. Findings: A review of hospital policy, “EMTALA-Transfer Policy,” Policy # LL.EM.001.RRMC.4, and dated as 10/22/2024, revealed in part: “POLICY: Any transfer of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf or by a physician order with the appropriate physician certification as required under EMTALA. 1. Transfer of Individuals Who Have Not Been Stabilized a. If an individual who has come to the emergency department has an EMC that has not been stabilized, the hospital may transfer the individual only if the transfer is an appropriate transfer and meets the following conditions: i. 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 the EMTALA and of the risks and benefits of such transfer. The request must be in writing and indicated the reasons for the request as well as indicate that the individual is aware of the risks and benefits of transfer; or ii. A physician 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 the woman in labor, to the woman or the unborn child, from being transferred. The certificate must contain a written summary of the risks and benefits upon which it is based; or Note: The date and time of the physician or QMP certification should match the date and time of the transfer. b. A transfer will be an appropriate transfer if: 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; iv. The transfer is effected through qualified personnel and transportation equipment as required including the use of necessary and medically appropriate life supports measures during the transport. c. Higher Level of Care: A higher level of care should be the more likely reason to transfer an individual with an EMC that has not been stabilized. PROCEDURES: 1. Transfers of Individuals Who Are Not Medically Stable Requirements Prior to Transfer. After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. The following requirements must be met for any transfer of an individual with an EMC that has not been stabilized: a. Minimize the Risk. b. Individual’s Request or Physicians Order. Any transfer to another medical facility of an individual with an EMC must be initiated either by a written request for transfer from the individual or the legally responsible person acting on the individual’s behalf or by a physician order with the appropriate physician or QMP and physician certification as required under EMTALA. Any written request for a transfer to another medical facility from an individual with an EMC or the legally responsible person acting on the individual’s behalf shall indicate the reasons for the request and that he or she is aware of the risks and benefits of the transfer. c. Request To Transfer made To Receiving Facility. d. Document the Request e. Send Medical Records f. Physician Certification of Risks and Benefits. A physician must sign an express written certificate that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provisions 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 unborn child, from being transferred. The certification should meet the following requirements: -The certification must state the reason for the transfer. The narrative rationale need not be a lengthy discussion of the individual’s medical condition as this can be found in the medical records but should be specific to the condition of the patient upon transfer. -The certification must contain a complete picture of the benefits to be expected from appropriate care at the receiving facility and the risks associated with the transfer, including the time away from an acute care setting necessary to arrect the transfer. -The date and time of the physician certification should closely match the date and time of the transfer. -Certifications may not be backdated. g. QMP Certification. If a physician is not physically present at the time of the transfer, a QMP may sign the certification, after consultation with a physician, and transfer the individual as long as the medical benefits expected from transfer outweigh the risks. If a QMP signs the certification, a physician shall countersign it within 24 hours or a reasonable time period specified by the hospital bylaws, rules or regulations.” A review of the Medical Executive Bylaws and Rules failed to reveal guidelines related to ED Physician countersigning the APP’s Physician Certification for transfer from ED to ED. A review of an untitled hospital document that was identified on 06/08/2026 at 12:20 p.m. by S3DED as the hospital’s EMTALA Physician’s Certification and Patient Consent to Transfer Form (this document will be further identified in this tag as such) revealed the following sections to be completed: -Sections I. - IV. To be completed by the physician and included the subsections: Medical Condition and Diagnosis; Patient Stabilization; Physician Certification; Reason for Transfer; Risks and Benefits for transfer; and Mode/Support During Transfer; -Sections V. - VI. To be completed by the nursing staff and included the subsections: Receiving Facility and Individual; Receiving Provider; Accompanying Documentation; and Time of Transfer; and -Section VII. To be acknowledged by the patient and included the Patient Consent to Medically Transfer or the Patient Request for Transfer. A review of medical records revealed the following: Patient #1 A review of Patient #1’s medical record dated 05/19/2026 revealed the patient being transferred to Provider A at approximately 10:24 p.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S4MD checked the box next to, “Patient Stable For Transfer,” however S4MD failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN” S4MD failed to document the mode of transport, necessary medical equipment and the qualified personnel to effect the transfer; and the physician failed to document the date and time of the authentication of this section; and -Section VII. “PATIENT CONSENT TO MEDICALLY INDICATED TRANSFER or PATIENT REQUEST FOR TRANSFER” S5RN failed to document the date and time of the authentication of this section. Patient #2 A review of Patient #2’s medical record dated 05/31/2026 revealed the patient being transferred to Provider A on 06/01/2026 at approximately 12:37 a.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I “MEDICAL CONDITION” S6PA checked the box next to, “Patient Stable For Transfer,” and authenticated this section, however S7DO (ED Physician) failed to countersign the Physician Certification; and -Section IV “ MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN” S6PA authenticated this section, however S7DO (ED Physician) failed to countersign this section as it related to the mode of transport, necessary medical equipment and the qualified personnel to effect the transfer. Patient #3 A review of Patient #3’s medical record dated 04/30/2026 revealed the patient being transferred to Provider A on 05/01/2026 at approximately 2:00 a.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S10MD failed to indicate the condition of the patient - stable versus unstable and failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S10MD failed to indicate the level of care/services unavailable at this facility and available at the receiving hospital that would benefit the patient; and -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S10MD failed to reveal the mode, the necessary medical equipment or the qualified personnel required for the transfer. S10MD failed to document the date and time of the authentication of this section. Patient #7 A review of Patient #7’s medical record dated 04/10/2026 revealed the patient being transferred to Provider A on 04/11/2026 at approximately 1:02 a.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S8MD failed to indicate the condition of the patient - stable versus unstable and failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section II. “REASON FOR TRANSFER:” S8MD failed to indicate the reason for transfer; -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S8MD failed to indicate the level of care/services unavailable at this facility and available at the receiving hospital that would benefit the patient; and -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S8MD selected the mode of transfer as via helicopter, however this section failed to reveal the necessary medical equipment and the qualified personnel required for the transfer. S8MD failed to document the date and time of the authentication of this section. Patient #8 A review of Patient #8’s medical record dated 03/09/2026 revealed the patient being transferred to Provider A on 03/09/2026 at approximately 4:30 p.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S9MD checked the box next to, “Patient Stable For Transfer,” however S9MD failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; and -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S9MD failed to reveal the mode, the necessary medical equipment and the qualified personnel required for the transfer. S9MD failed to authenticate, date and time this section. Patient #9 A review of Patient #9’s medical record dated 02/20/2026 revealed the patient being transferred to Provider A on 02/20/2026 at approximately 11:56 p.m.. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S10MD failed to indicate the condition of the patient - stable versus unstable and failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section II. “REASON FOR TRANSFER:” S10MD failed to indicate the reason for transfer; -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S10MD failed to indicate the level of care/services unavailable at this facility and available at the receiving hospital that would benefit the patient; and -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S10MD failed to reveal the mode, the necessary medical equipment and the qualified personnel required for the transfer. S10MD failed to authenticate, date and time this section. Patient #11 A review of Patient #11’s medical record dated 02/03/2026 revealed the patient being transferred to Provider A on 02/03/2026 at approximately 2:30 p.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S11MD failed to indicate medical risks (i.e.: Deterioration of condition in route; Worsening of condition or death if you stay here; Risk of traffic delay/accident resulting in condition deterioration or death; and/or other risks) associated with the transfer of the patient. Patient #12 A review of Patient #12’s medical record dated 01/27/2026 revealed the patient being transferred to Provider A on 01/28/2026 at approximately 12:57 a.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S10MD failed to indicate the condition of the patient - stable versus unstable and failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S10MD failed to indicate the level of care/services unavailable at this facility and available at the receiving hospital that would benefit the patient; Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S10MD failed to reveal the mode, the necessary medical equipment and the qualified personnel required for the transfer. S10MD failed to document the date and time of the authentication of this section; and -Section VII. “PATIENT CONSENT TO MEDICALLY INDICATED TRANSFER or PATIENT REQUEST FOR TRANSFER” The nurse [unable to identify signature] failed to indicate if the patient was consenting to transfer or requesting to transfer as the selection under the patient’s request to transfer was completed as follows: “The reason I request to transfer is: higher level of care”. The nurse failed to document the date and time of the authentication of this section. Patient #13 A review of Patient #13’s medical record dated 01/18/2026 revealed the patient being transferred to Provider A on 01/18/2026 at approximately 8:39 a.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S12MD checked the box next to, “Patient Stable For Transfer,” however S12MD failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; and Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S12MD failed to document the time of the authentication of this section. Patient #14 A review of Patient #14’s medical record dated 01/02/2026 revealed the patient being transferred to Provider A on 01/02/2026 at approximately 6:00 p.m. A review of the medical record failed to reveal a provider order for transfer and failed to reveal the type of transfer being requested - physician certification or the patient/legally responsible individual requested. A review of the EMTALA Physician’s Certification and Patient Consent to Transfer Form revealed the following sections of this document as incomplete: -Section I. “MEDICAL CONDITION” S11MD checked the box next to, “Patient Stable For Transfer,” however S11MD failed to document the date and time of the authentication of this section. This section of the physician certification failed to closely match the time of the patient’s transfer; -Section III. “RISKS AND BENEFITS FOR TRANSFER:” S11MD failed to indicate medical risks (i.e.: Deterioration of condition in route; Worsening of condition or death if you stay here; Risk of traffic delay/accident resulting in condition deterioration or death; and/or other risks) associated with the transfer of the patient; and -Section IV. “MODE/SUPPORT DURING TRANSFER AS DETERMINED BY PHYSICIAN:” S9MD failed to reveal the mode, the necessary medical equipment and the qualified personnel required for the transfer. S11MD failed to authenticate, date and time this section. In an interview on 06/09/2026 at p.m. S13MDDED confirmed the use of the above-mentioned form by the ED physicians. S13MDDED confirmed the form should be completed in its entirety for all ED transfers out of this hospital. S13MDED confirmed the form would serve as the physician certification and the transfer agreement or request for transfer by the patient. In interviews during medical record review on 06/09/2026 from 3:00 p.m. to 4:30 p.m. and on 06/09/2026 from 8:45 a.m. to 12:40 p.m., S2DED confirmed the above-mentioned findings while navigating the electronic medical records for surveyor review.”

“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: 48051 Based on observation and interview, the hospital failed to ensure the nurse call system was functioning via call buttons located on the side rails of patient beds in Rooms “a” - “d.” Findings: Observations made during a walk-though of Unit A on 01/05/2026 from 2:50 p.m. to 3:10 p.m. revealed nurse call buttons were located on the side rails of the patient beds in Rooms “a” - “d.” Each bed’s right and left side rail contained two nurse call buttons located on its interior side (mattress side) and one nurse call button located on its exterior side. When each of these call buttons were depressed, they did not activate the nurse call system at the nurses’ station, illuminate the call light above the entry door or activate an audible sound that would be indicative of a patient calling for assistance. This had the potential to place undue distress and/or harm on a patient and/or a family member attempting to call staff for assistance. In an interview on 01/05/2026 and present during this walk-through, S5DCC and S6NL confirmed the above findings.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48537 Based on record reviews and interviews, the hospital failed to ensure licensed nurses adhered to policies and procedures of the hospital. This deficient practice was evidenced by the failure to ensure hospital post fall process policy and procedure was implemented by nursing staff for 1 (#3) of 3 (#1 - #3) patients reviewed for falls. Findings: Review of the hospital’s policy #166 titled “Fall Prevention” with a last revision date of 04/2022, revealed in part, “I. Purpose: 1. Provide a standard, common definition for falls. 2. Provide evidence-based guidelines for stratification of individualized patient risk for falls. 3. Outline the standard of care for all patients regardless of risk stratification. 4. Outline documentation requirements for nursing. 5. Establish post-fall huddle and Serious Safety Event (SSE) reporting guidelines. II. Definitions: A patient fall is a sudden, unintentional descent, with or without sustained injury that results in the patient coming to rest on the floor, on or against some other surface, on another person, or on an object. This includes all unassisted and assisted falls regardless of the patient’s age or admission status. III. Policy and Procedures Statements: 1. All patients will be evaluated for fall potential through completion of the appropriate Falls Risk Assessment. This will occur during the admission process; following a change in medical condition and/or level of care; and post fall. 2. Based on the level of fall risk, nursing interventions will be initiated and will be captured on the patient’s plan of care. 3. Regardless of risk stratification, standard of care fall prevention elements will be implemented on all patients. Assessment: 3. Reassessment of fall risk will occur, at minimum, once per shift; following a change in medical condition and/or level of care; and post fall. Standard of Care: 1. Regardless of risk score or level of stratification, the following will be in place for all patients across the facility. Documentation: 3. Every patient should have fall prevention measures listed as part of their individualized plan of care. Post-Fall Process: 2. Notifications of the fall - a. At a minimum, the Attending Physician, Nursing Leader, and patient’s legal representative will be notified as soon as possible. b. All notifications will be documented in the EHR. 3. Reporting - a. For each patient fall, the nurse will document in the Post Fall Assessment intervention within the EHR. Alternative Areas: 1. All Emergency Services areas will follow the above policy details with the exception of assessment timing and frequency. b. Patients presenting to Emergency Services areas, will be assessed for fall risk once per encounter and as needed with any change in patient status. Those patient in an ER Hold status (i.e. admitted patients holding in the ER due to lack of inpatient beds), will follow the assessment expectations for inpatients according to the aforementioned intervals.” Review of the “Manage Refer Contact Notify” report in Patient #3’s medical record dated 02/08/2025 at 12:30 PM by S4RN revealed only the provider had been notified of Patient #3’s fall. There was no documented record of notification attempts to nursing leadership or Patient #3’s legal representative. Review of the “Post Fall Assessment” in Patient #3’s medical record revealed it was created on 02/08/2025 at 8:32 AM by S4RN. No additional changes or modifications were made to the assessment until 02/10/2025 at 9:41 PM when it was completed at the time of the Patient #3’s discharge. On 04/02/2025 at 11:26 AM, an interview was conducted during record review with both S2RMD and S3ERNM. Both confirmed after thorough review of Patient #3’s medical record, there were no documented attempts by nursing staff to notify Patient #3’s legal representative and nursing leadership and S2RMD and S3ERNM aggreed it should have been documented. S2RMD and S3ERNM also reviewed the “Post Fall Assessment” and confirmed no new interventions were documented after the fall on 02/08/2025 at 12:30 PM and S2RMD and S3ERNM agreed new interventions should have been documented.”

“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: 20310 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 the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice was evidenced by failure to provide an appropriate medical screening exam as evidenced by the physician failing to perform a neurological and psychiatric examination for 1 (#1) of 11 patients (#1, 3, 4, 7, 9, 10, 11, 13, 14, 15, 20) who presented to the emergency department with a psychiatric emergency medical condition (See findings at A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 20310 Based on record review and interview, the hospital failed to provide an appropriate medical screening exam as evidenced by the physician failing to perform a neurological and psychiatric examination.for 1 (#1) of 11 patients (#1, 3, 4, 7, 9, 10, 11, 13, 14, 15, 20) who presented to the emergency department with a psychiatric emergency medical condition. Findings: Review of the medical record for Patient #1 dated 06/06/2024 at 6:07 p.m. revealed a 24 year old male who presented to the emergency department via EMS with complaints of having done meth yesterday and has not slept in the last couple of days. Per EMS, the patient was found wandering the streets naked and local police called them. The patient denied any chest pain or shortness of breath. The patient reported having a history of meth use for which he has been in and out of rehab. The patient was unsure when his last rehab stay was. Patient #1 was triaged as level ESI 2/Emergent. At 6:10p.m., a Rapid Initial Assessment was conducted by an RN. The assessment revealed the patient was restless, tachycardic, unable to sit still, anxious, afebrile, pupils 5+, no acute respiratory distress. His Broset (violence/aggression) score was 0. He was noted to remove his IV access more than once. At 6:15 p.m., an HPI was conducted by the NP - Chief complaint: meth use, wants help. The physical exam revealed he was awake, alert, in no acute distress, well appearing, well developed, well hydrated, well nourished, cooperative, not toxic appearing. Psychiatric exam revealed the following: affect NL, mood NL, not suicidal, not homicidal, no hallucinations, cognitive function NL, judgment/insight NL, thought content NL. Labwork included: Chemistry, Hematology, Toxicology - positive for marijuana; an EKG was performed. He was treated with Ativan x2 doses; Benadryl x1 dose; Nicotine patch; Geodon x1 dose. Re-evaluation notes revealed: called and spoke with Inpatient Rehabilitation Center A - accepted patient and will send someone to get him as soon as he was ready for discharge. The patient was in agreement with the plan of care, and was discharged on 06/06/2024 at 11:47 p.m. in stable condition when rehab van picked up up for transport to the rehab. He was counseled regarding diagnosis, lab results, need for followup, when to return to ED. On 06/07/2024 at 1:21 a.m., Patient #1 returned to the emergency department with complaint of drug overdose. He was triaged as level ESI 1 - Resuscitation. On 06/07/2024 at 1:21 a.m., a Rapid Initial Assessment was conducted by an RN. The assessment notes revealed that he was released from the hospital at 12:11 a.m. to the rehabilitation facility. Upon arrival to the rehab, the patient was noted to have pinpoint pupils and was unresponsive. Narcan was administered per EMS; he arrived to the emergency department via EMS with restraints intact due to combativeness. He arouses to tactile and painful stimuli. No respiratory compromise noted. Pupils pinpoint. A PEC was completed by S1MD on 06/07/2024 at 1:25 a.m. for Patient #1 due to overdose on the way to Inpatient Rehabilitation Center A, polysubstance abuse, and bizarre behavior. Mental condition was assessed as bizarre, avoidant, positive for hallucinations. Documented revealed he was not currently suicidal, homicidal or violent; Opinion documented: dangerous to self; gravely disabled; unwilling/unable to seek voluntary admission. On 06/07/2024 at 1:29 a.m., the HPI notes documented by S1MD for Patient #1 revealed: he had been in the ED here earlier today for strange behavior, methamphetamine positive and voluntarily went to check himself in at the drug rehabilitation facility. He had a ride there on their bus and while checking in he lost consciousness and had pinpoint pupils. He responded to Narcan. Arrives with ongoing bizarre behavior. The physical exam conducted by S1MD revealed: VS normal; avoiding interaction. Psychiatric exam revealed: bizarre affect, hallucinations. Labwork included: Chemistry, Hematology. Toxicology - positive for THC, amphetamines; CXR and EKG was performed. Treatment included Naloxone x1 dose; IV fluids; Ondanestron x1 dose. Re-evaluation notes documented by S1MD revealed: 24 year old presents complaint of bizarre behavior, overdose and ongoing substance abuse. He is obviously a danger to himself at this point having overdosed on his way to rehabilitation center. Will continue to observe. Will medically clear. Will PEC for his protection. Re-evaluation progress notes documented by S1MD revealed: Patient’s labs benign other than elevated CK. Will give additional 20cc/kg normal saline bolus. Patient is medically cleared for transfer for psychiatric care. Clinical Impression: polysubstance abuse, overdose by ingestion, psychosis. Disposition Decision on 06/07/2024 at 2:00 a.m: transfer for psychiatric services. Certification was completed for transfer and signed by S1MD with: medical condition; reason for transfer; risks and benefits for transfer; mode/support during transfer; receiving facility and individual; accompanying documentation. Nursing assessments were completed hourly for ingestion. Nursing Notes: 06/07/2024 at 6:00 a.m. - Patient PEC; moved to pod room; patient stable and medically clear at this time; suicide safe environment. Review of patient monitoring forms completed every 15 minutes from 06/07/2024 at 6:00 a.m. until discharge at 11:15 a.m. revealed behavior was documented as agitated/sleeping/sitting - no combativeness or restraint use documented. Review of the nurse notes revealed: On 06/07/2024 at 10:45 a.m., Patient #1 was accepted for admission to Psychiatric/Behavioral Hospital B with accepting MD noted. At 10:53 a.m., EMS was contacted to set up transportation, which was to be available within an hour. At 11:12 a.m., the nurse documented report was given to the receiving hospital. 06/07/2024 at 11:16 a.m., Patient #1 departed via EMS to the receiving psychiatric hospital in stable condition. Review of Patient #1’s medical record retrieved from Psychiatric/Behavioral Hospital B revealed an admission date of 06/07/2024. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, S4RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S2Psych was notified of patient arrival and current situation. PRN order was given at this time. Haldol 15mg IM, Ativan 4mg IM, and Benadryl 50mg IM. Patient #1 remained on stretcher in 4 point restraints due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by LPN. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMTs could not release patient out of restraints due to patient trying to flip stretcher. Review of Patient #1’s medical record that the provider failed to evaluate, assess or treat Patient #1’s psychiatric condition prior to transferring the patient back to Rapides Regional Hospital. In an interview on 07/15/2024 at 1:39 p.m., S2DON verified Psychiatric/Behavioral Hospital B had 14 patients on 06/07/2024. He stated that did not include Patient #1. He verified the hospital had available beds for Patient #1. S2DON stated Patient #1 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #1 in restraints to get Patient #1 off the EMS stretcher. S2DON verified Patient #1 would have been safer here than being transferred back to the emergency department. After reviewing the admission criteria policy, S2DON verified that Patient #1 did meet admission criteria and did not meet any exclusionary criteria. On 06/07/2024 at 1:26 p.m., Patient #1 returned (for the third time in 19 hours) to the emergency department via EMS, triaged as level ESI 2/Emergent. Chief complaint: Drug use. On 06/07/2024 at 1:31 p.m., a Rapid Initial Assessment was conducted by S2RN. Assessment revealed the patient was recently sent to Psychiatric/Behavioral Hospital B, but was “too combative”, so they gave a B52 and then sent back here; patient denies complaints; awake, alert and oriented x3, respirations even and unlabored, bilateral breath sounds clear to auscultation, Skin warm, dry and pink. Appears well. On 06/07/2024 at 1:32 p,m., an HPI was documented by S3DO and revealed: 24 year old male with history of drug abuse presented to the emergency department from psychiatric facility as they would not admit him due to agitation. Patient seen yesterday in emergency department. He unintentionally overdosed going to a rehab center. He was put under physician emergency certificate by previous doctor for this reason. Patient denies any SI, HI, AVH. Does report he would like to receive help for substance abuse though he would like to go to his grandmother’s house where he stays before he checks in. No medical complaint. Further review of the assessment by S3DO revealed: Detailed Suicide Risk: positive suicide risk screen - no; 3 month suicide and self-injurious behavior - no SI; most severe SI past month - No SI; Other risk factors - gender; recent clinical status - substance abuse/dependence; overall level suicide risk - low risk. Risk stratification: suicide - adult risk factors reviewed. Past medical history - combative at facility; now sleeping. Continued review of the medical record failed to reveal a thorough neurological or psychiatric assessement was conducted. The physical exam did not contain a psychiatric section. There was no documentation of the patient’s narrative of events surrounding his overdose and agitated behavior. The physician failed to document any discussion with the patient about what substances he potentially consumed or that he reached out to family for collateral information. Review of the Re-evaluation notes documented by S3DO revealed: 24 year old male presented with agitation as he was being checked into a psychiatric facility. I reviewed physician emergency certificate from yesterday by previous physician. Will rescind this as patient without SI, HI, AVH. He is alert and oriented. He does admit to drug use though denies any suicidal intent. He does report he would like rehab services though he does not want to go until he can talk to his family. He was discharged to his family’s care. 06/07/2024 1:35 p.m. - discharged to home; counseled regarding diagnosis, need for follow-up, when to return to ED. Instructions - Drug abuse. Additional instructions - Please present to rehab services. Please return at any time for re-evaluation or feeling unsafe in any way. No referrals. Review of the Nursing Notes dated 06/07/24 at 3:00 p.m. revealed discharge instructions were given to and verbalized understanding by Patient #1 and his mother; patient left to home in stable condition. On 07/18/2024 at 1:15 p.m., an interview was conducted with S2RN, who confirmed she was working in the ED on the day shift when Patient #1 was transferred to the psychiatric hospital, and also when he returned from the psychiatric hospital to the ED. S2RN stated Patient #1 did not want to go to the psychiatric hospital. She explained the PEC to him. She stated he was not violent or belligerent, but was not happy with the PEC or going to the psychiatric hospital, and was resistant - he wanted to go to the rehab. S2RN stated she talked with his mother, and she was “not a fan” of the PEC and wanted him in rehab as well, not psych. S2RN confirmed that when a doctor completes a PEC and refers a patient to the psychiatric hospital after medical clearance, the nurses mass fax the paperwork through the online system to psychiatric facilities. The admissions staff from the accepting facilities contact the sending hospital for details and get approval from their provider (MD), and confirm acceptance of the patient; the nurse from the sending hospital places a call to the receiving facility to give report as the patient is going out of our facility to theirs. When Patient #1 left the ER to go to the psychiatric hospital , he was still resistant to psychiatic treatment, but was calm. He did not receive any sedatives while he was in the ER before he left, and was calm when he returned a few hours later - she never saw him become combative or belligerent. After Patient #1 returned to the ER and S3DO saw him, she talked with S3DO - he said the patient denied SI/HI was okay for discharge home, and he rescinded the PEC. She stated she pushed Patient #1 in the wheelchair to the car, gave discharge instructions to his mom and he left with his mom. She stated he said he planned to go to rehab the next day. S2RN further added that the rehab wouldn’t have accepted him until he was clean for 24 hours. On 07/18/2024 at 12:20 p.m., a telephone interview was conducted with S1MD. He confirmed he was working in the ER on 06/06/2024, the evening that Patient #1 was brought into the ER by EMS. He recalled the patient had a drug overdose and was exhibiting bizarre behavior (found out in his yard naked); he recalled that the patient was seen by him and then transferred to the drug rehab facility for substance abuse treatment, and that the patient was picked up by the treatment center’s bus for transfer. S1MD recalled that Patient #1 returned shortly after he left via EMS after overdosing on the way to the rehab facility and had received Narcan. He confirmed that he examined Patient #1 on the return visit and conducted a PEC on the patient. He stated the PEC was performed in order to allow time to complete the observation and do a workup for metabolic causes for the psychosis. After medical clearance, if a patient does not improve, he is referred for psychiatric treatment and the nurse will then initiate contact with facilities for placement. He stated it is not common practice for the sending and receiving doctors to talk before transferring the patient to a psychiatric facility. S1MD recalled that in the case of Patient #1, he felt the patient was too impulsive and lacked control, so he wanted him sent to an inpatient psychiatric facility for evaluation and treatment. He further stated he normally does not PEC for intoxication and overdose patients, “when they become lucid, they will be combative and averse to treatment, so we try to get them to go voluntarily to seek treatment for substance abuse,” but Patient #1 had been in the ED twice within the last 24 hours. He stated he doesn’t feel like he would have rescinded the PEC, but stated that “sometimes a PEC can harden a patient against therapy; the question for this young man was whether the PEC would benefit or hinder overall treatment. I felt he was a danger to himself when I PEC’d him, and was concerned about his impulse control, since he didn’t make it to the rehab the first time. We usually use our own judgment to PEC, rather than consult psychiatrist - we leave that to the behavioral facility.” S1MD confirmed the patient was not combative or belligerent when he declared him medically stable and ready for transfer to the psychiatric hospital on 06/07/2024 at 2:00 a.m., but did not personally see him for the remainder of the night before he left his shift. He stated if the patient had any changes in behavior, the nurses would have reported that to him. On 07/18/2024 at 12:45 p.m., a telephone interview was conducted with S3DO, who confirmed he was working in the ED on the afternoon of 06/07/2024, when Patient #1 was returned from the psychiatric hospital via EMS. He stated he was told that he was too agitated at the psychiatric hospital for the staff to handle and they sent him back to the ED. He stated the patient was calm and cooperative when he assessed him. He talked with him and the patient stated he was seeking rehab services, and didn’t need a psychiatric hospital. He stated that Patient #1 “freaked out” when he realized he was sent to a psychiatric hospital rather than a rehab facility. When he returned to the hospital ED he was alert, oriented and sober. He admitted he was a drug addict and wanted rehab, but said he wanted to go to his grandma’s house first, and then to rehab. S3DO stated the standard of care for overdose treatment is to observe for a few hours for recovery (in case they need Narcan, etc), and then discharge them. It is generally not their practice to PEC a patient if the overdose was unintentional and without suicidal ideations. He stated Patient #1 did not have suicidal ideations/homicidal ideations or audiovisual hallucinations at the time he returned from the psychiatric hospital. He further stated that it is not his view to take away a patient’s rights due to drug overdose alone; he was clinically sober and acting normally at the time of discharge, so there was no reason for the PEC and he had no known psychiatric history. He confirmed that he did review all the notes from the 2 previous ED visits earlier that day, and stated it seemed a reasonable plan to him for Patient #1 to go home with his mom and then to rehab - that is what they both agreed to. His mom picked him up and took him home with understanding and agreement of that plan. The nurse went over the discharge instructions. When asked if he was aware if Patient #1 was admitted to the reahbilitation facility, he stated he heard he had overdosed and died a few days after discharge from the hospital. On 07/18/2024 at 10:00 a.m., in a phone interview with the mother of Patient #1, she stated Patient #1 was discharged on Friday 06/07/2024 from Rapides Hospital and was to go to Rehab on Saturday 06/08/2024, but he wanted to use. He got a room at the casino and went home with individuals he did not know and he overdosed at their house on 06/11/2024.”

“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: 38777 Based on record review and interview, the hospital failed to ensure the Emergency Department Physicians informed Patient #2, or a legally responsible person acting on the patient’s behalf, in writing of the risks and benefit of the transfer as evidenced by failure to have documented evidence that 1 (#2) of 20 ED patients (#1-#20) (or their responsible party) transferred were informed of the risks and benefits of transfer in writing. Findings: Patient #2 presented to the ED 11/04/2023 at 12:00 p.m. via ambulance. A review of Patient #2’s medical record revealed he presented to the Emergency Department after a motor vehicle accident with open deformity to the medical aspect of the right foot or ankle. CT of right ankle completed 11/4/2023 at 12:59 p.m. showed a severely comminuted open fracture involving the calcaneus. Fracture extends into the subtalar joint and calcaneal cuboid articulation. Fragments are displaced upwards of 2.5 cm. There are bone fragments seen at the skin surface posteriorly. There is punctuate debris in the wound association. Soft tissue gas is also seen within the ankle joint and anterior soft tissues. Marked soft tissue swelling is also noted. Patient #2 Diagnosis: motor vehicle collision, right femoral fracture, abrasions to multiple sites, open fracture of calcaneus, right pneumothorax, compression fracture of T9 vertebra, fracture of sternum with retrosternal contusion, bilateral pulmonary contusion. Transfer request time: 3:05 p.m. 11/04/2023. Transfer accepted: 4:16 p.m. 11/04/2023 for orthopedics higher level of care. Departed 11/04/2023 at 6:52 p.m. Further review failed to reveal the Emergency Department Physicians informed Patient #2, or a legally responsible person acting on the patient’s behalf, in writing of the risks and benefit of the transfer and request for the transfer. In an interview on 11/8/2023 at 12:00 p.m. S3RM and S4VPRQ reviewed and verified the certified medical record for Patient #2 did not contain required transfer documentation and consent.”