Christus Ochsner St Patrick Hospital

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to have an adequate number of nursing staff to provide care and supervision of the patients. This deficient practice was evidenced by the hospital’s behavioral health unit was short staffed according to the hospital’s staffing matrix. Findings: Review of the patient census dated 11/11/2025 at 10:00 AM revealed there were 15 inpatients on the behavioral health unit. Review of the staffing matrix for the behavioral health unit revealed: Census: 15 Charge Nurse: 1 Registered Nurse (RN): 3 Nurse Aid: 3 Unit Secretary: 1 Review of the staffing schedule dated 11/11/2025 day shift revealed in part, Unit 54 (behavioral health unit) Charge Nurse: 1 Registered Nurse: 2 Mental Health Technician (MHT): 2 MHT: 1 (12:00 PM - 7:00 PM) 1 registered nurse call in. The behavioral health unit was short 1 RN on 11/11/2025 from 7:00 AM - 7:00 PM and short 1 MHT on 11/11/2025 from 7:00 AM - 12:00 PM. On 11/20/2025 at 1:01 PM S1CNO confirmed on 11/11/2025 day shift (7:00 AM - 7:00 PM) the behavioral health unit was short 1 RN. S1CNO further confirmed on 11/11/2025 the behavioral health unit was short 1 MHT from 7:00 AM - 12:00 PM.”

“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 provide documented evidence to indicate an appropriate transfer was provided to patients who presented to the hospital’s emergency department (ED) with an emergency medical condition. This deficient practice was evidenced by: 1.) failing to have documented evidence of a physician certificate of transfer which included risks and benefits of the transfer for 3 (#F3, #F6, #F7) of 7 transferred patients from a total sample of 10; and 2.) failing to provide medical treatment of an emergency medical condition prior to transferring the patient to a psychiatric hospital for 1 (#F7) of 4 psychiatric patients that were transferred from a total sample of 10. Findings: Review of the hospital’s policy titled “EMTALA - Transfer”, revised/reviewed 12/2024, revealed in part, “V. Process or Procedures: 10. Restricting transfer until the individual is stabilized. If an individual at the Hospital has an emergency medical condition that has not been stabilized, the Hospital may not transfer the a.) Individual unless the transfer can be appropriately arranged and: 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 EMTALA (Emergency Medical Treatment and Active Labor Act) and of the risks 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 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 outweighs 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 QMP (qualified medical person) has signed a certification after a physician in consultation with the QMP, 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.” 1.) Failing to have documented evidence of a physician certificate of transfer which included risks and benefits of the transfer for 3 (#F3, #F6, #F7) of 7 transferred patients from a total sample of 10. Patient #F3 Review of Patient #F3’s ED visit record revealed Patient #F3 presented to the ED on 11/11/2025 at 5:56 AM. Review of the ED provider note dated 11/11/2025 revealed in part, “History: Patient presents with acute psychosis. Patient with HTN (hypertension), hypothyroidism, DM (diabetes mellitus) type I, bipolar disorder repeatedly calling 911 and stating to police that he has been exposed to radiation and that Terrace [sic] are trying to get him. He reports that his house is being burglarized by his neighbors. He reports that he was calling the police to report a crime.” Further review of the document revealed in part, “ED Course: 12:15 PM: Patient awoke and is angry. He is yelling and threatening to leave. He is not calming down with talking to him. I ordered Geodon, Benadryl, Versed.” “1:30 PM: Patient cleared for inpatient psychiatry.” “4:25 PM: Patient fighting EMS (emergency medical services) and security when EMS arrived to transport him. Ordered Haldol, Versed, Benadryl to help the patient calm down and cooperate with care.” Further review of the document revealed in part, “Medical Decision Making: Patient with acute psychosis. I will PEC (Physician’s Emergency Certificate) this patient for being gravely disabled and unwilling to seek psychiatric care. I ordered Haldol, Versed, Benadryl to help this patient calm down for his safety and ours.” “Diagnosis: acute psychosis.” Review of the ED Care Timeline revealed in part, “1:22 PM Transfer disposition selected: ED disposition set to transfer to another facility.” Further review of Patient #F3’s ED visit record dated 11/11/2025 failed to reveal a Transfer Consent/Request/Refusal Form. Review of a blank Transfer Consent/Request/Refusal Form revealed in part, Part Two: Physician Assessment and Certification. This form included transfer requirements, patient condition, and risks and benefits of the transfer. In an interview on 11/19/2025 at 4:16 PM, S1CNO confirmed the Transfer Consent/Request/Refusal Form was not included in Patient #F3’s medical record. Review of Patient #F3’s medical record from hospital ‘A’ revealed Patient #F3 was admitted on 11/11/2025 at 6:30 PM. Further review of the record revealed in part, Patient #F3 was admitted under a PEC for acute psychosis. Patient #F6 Review of Patient #F6’s ED visit record revealed Patient #F6 presented to the ED on 11/05/2025 at 9:36 AM. Review of the ED provider note dated 11/05/2025 revealed in part, “HPI (history of present illness): [stated age] female, brought into the ER (emergency room) for evaluation of anxiety and fear, patient was involved in a shooting 2 weeks ago, she had no injury, but since then she has been afraid to leave her home, she refuses to go to school, she has been acting out. Patient states that she feels anxious and is afraid, she has racing thoughts, and is unable to sleep. She denies being suicidal or homicidal.” Further review of the document revealed in part, “ED Course: “11:00 AM: Patient access saw and evaluated patient, patient is extremely depressed, anxious, withdrawn, unable to perform activities of daily living due to anxiety, she has had passive SI (suicidal ideation) with a previous attempt in the past. At this time we will proceed with PEC for further evaluation and treatment. MD (medical doctor) to assume care of the patient for PEC purposes.” “Diagnosis: current severe episode of major depressive disorder with psychotic features without prior episode.” “ED Dispo (disposition): transfer to another facility.” Further review of Patient #F6’s ED visit record dated 11/05/2025 failed to reveal a Transfer Consent/Request/Refusal Form. Review of a blank Transfer Consent/Request/Refusal Form revealed in part, Part Two: Physician Assessment and Certification. This form included transfer requirements, patient condition, and risks and benefits of the transfer. In an interview on 11/20/2025 at 11:11 AM, S2DBH confirmed the Transfer Consent/Request/Refusal Form was not included in Patient #F6’s medical record. Review of Patient #F6’s medical record from hospital ‘B’ revealed Patient #F6 was admitted on 11/05/2025 at 3:40 PM. Further review of the record revealed in part, Patient #F6 was admitted under a PEC with diagnoses of severe recurrent major depression without psychotic features and posttraumatic stress disorder. Patient #F7 Review of Patient #F7’s ED visit record revealed Patient #F7 presented to the ED on 10/24/2025 at 9:11 AM. Review of the ED provider note dated 10/24/2025 revealed in part, “Medical Decision Making: Patient was brought in by EMS. They report the patient used meth an hour prior to their call. He was hallucinating and banging on his neighbors door. Patient denies SI/HI (homicidal ideation). CPK (creatine phosphokinase) came back at 1200. Patient was given a total of 2 L (liter) normal saline and lactic was redrawn. Urine was positive for leukocytes, otherwise workup was essentially normal. Patient was PEC due to being gravely disabled. Will be admitted to psychiatric unit for further evaluation and treatment.” Further review of the document revealed in part, “Diagnosis: psychosis, unspecified psychosis type, acute bacterial conjunctivitis of right eye.” Review of the ED Care Timeline revealed in part, “10/25/2025 12:08 AM Transfer disposition selected: ED disposition set to transfer to another facility.” Further review of Patient #F7’s ED visit record dated 10/24/2025 failed to reveal a Transfer Consent/Request/Refusal Form. Review of a blank Transfer Consent/Request/Refusal Form revealed in part, Part Two: Physician Assessment and Certification. This form included transfer requirements, patient condition, and risks and benefits of the transfer. In an interview on 11/20/2025 at 2:19 PM, S2DBH confirmed the Transfer Consent/Request/Refusal Form was not included in Patient #F7’s medical record. Review of Patient #F7’s medical record from hospital ‘C’ revealed Patient #F7 was admitted on 10/25/2025 at 9:55 AM. Further review of the record revealed in part, Patient #F7 was admitted under a PEC with a diagnosis of unspecified psychosis not due to a substance or known physiological condition. 2.) Failing to provide medical treatment of an emergency medical condition prior to transferring the patient to a psychiatric hospital for 1 (#F7) of 4 psychiatric patients that were transferred from a total sample of 10. Review of Patient #F7’s ED visit record revealed Patient #F7 presented to the ED on 10/24/2025 at 9:11 AM. Review of the ED provider note dated 10/24/2025 revealed in part, “Medical Decision Making: Patient was brought in by EMS. They report the patient used meth an hour prior to their call. He was hallucinating and banging on his neighbors door. Patient denies SI/HI. CPK came back at 1200. Patient was given a total of 2 L normal saline and lactic was redrawn. Urine was positive for leukocytes, otherwise workup was essentially normal. Patient was PEC due to being gravely disabled. Will be admitted to psychiatric unit for further evaluation and treatment.” Review of the creatine kinase laboratory results revealed the following: 10/24/2025 at 9:28 AM: 1234 10/24/2025 at 1:46 PM: 1263 10/24/2025 at 5:56 PM: 1160 10/24/2025 at 8:54 PM: 1155 Review of the nurse’s note dated 10/24/2025 at 11:32 PM revealed in part, “Called on call MH (mental health) provider (S5PMHNP) to review 4th repeated CK (creatine kinase) which has only decreased by 5 points. Last CK was 1160 and this current repeat is at 1155. Patient has now been down the this ER for 14 hours and has received multiple bags of IVF. Per S4MD earlier in the day, he was requesting the CK to go down to 800 or lower before acceptance. At this time, there will be no further fluids given per the ER provider and no need to further delay treatment for Mental Health. Reviewed with on call MH provider. The patient’s packet will be faxed out due to Unit 54 capability to treat due to lab criteria.” Further review of the ED provider note revealed in part, “Diagnosis: psychosis, unspecified psychosis type, acute bacterial conjunctivitis of right eye.” Review of the ED Care Timeline revealed in part, “10/25/2025 12:08 AM Transfer disposition selected: ED disposition set to transfer to another facility.” The facility failed to admit Patient #F7 for medical treatment of rhabdomyolysis. The benefits of transfer did not outweigh the risks as the patient showed an inappropriate resolution of rhabdomyolysis despite crystalloid fluid administration. Admission to an inpatient psychiatric facility would have placed the patient in a clinical setting without the staffing or resources necessary to monitor and treat rhabdomyolysis.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 44763 Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to provide care in a safe setting. This deficient practice was evidenced by: 1.) failing to provide a secure environment without a barrier to prevent psychiatric patients accessibility to other patients, staff members, and harmful medical equipment (see findings A-0144); 2.) the elopement of 2 (#1, #2) of 3 (#1, #2, #3) patients from the emergency department (ED) who were under a physician’s emergency certificate (PEC) (see findings A-0144); and 3.) failing to ensure security officers had current de-escalation training for 1 (S16SO) of 4 (S7SO, S8SO, S15SO, S16SO) personnel records reviewed who responded to the elopements of Patient #1 and Patient #2 (see findings A-0144). An Immediate Jeopardy situation was identified on 08/26/2025 at 12:28 PM and reported to S1CNO, S2QD, S3QM, S4DED, S5CFO and others. The Immediate Jeopardy situation was a result of the hospital failing to provide a secure environment without a barrier to prevent psychiatric patients accessibility to other patients, staff members, and harmful medical equipment. The Immediacy was lifted on 08/27/2025 at 11:50 AM when S1CNO provided a written removal plan. The plan included the following: 1.) Security Presence- Station a security officer in ED [emergency department] holding area when PEC [physician’s emergency certificate] patients are present to enhance patient safety and staff support. (See attached Louisiana PEC Detainment Process Flowchart) 2.) Root Cause Analyses (RCAs)- Initiate RCAs for all elopement incidents within one business day. RCA for 07/22/2025 patient elopement scheduled for 08/27/2025. 3.) Bed Closure- Close ED beds 13 through 16. 4.) Staff Education- All ED staff to complete de-escalation refresher training. Provided in a “read and sign” format. 5.) Staff Communication- Conduct ED staff huddles at 7:00 AM and 7:00 PM shifts for the next 14 days to cover the items below- first huddle at 7:00 AM on 08/27/2025. -Announce addition of security officer; -Communicate bed closures; -Reinforce expectation for completion of de-escalation refresher training prior to assuming care of a patient.”

“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 observations, record reviews, and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by: 1.) failing to provide a secure environment without a barrier to prevent psychiatric patients accessibility to other patients, staff members, and harmful medical equipment; 2.) the elopement of 2 (#1, #2) of 3 (#1, #2, #3) patients from the emergency department (ED) who were under a physician’s emergency certificate (PEC); and 3.) failing to ensure security officers had current de-escalation training for 1 (S16SO) of 4 (S7SO, S8SO, S15SO, S16SO) personnel records reviewed who responded to the elopements of Patient #1 and Patient #2. Findings: 1.) Failing to provide a secure environment without a barrier to prevent psychiatric patients accessibility to other patients, staff members, and harmful medical equipment. Review of the hospital’s policy titled “Patient Rights and Responsibilities”, revised/reviewed 09/20/2022, revealed in part, “IV. Policy: A. Patient Rights. The following rights are granted to all of our patients and are communicated to them as follows: 15. Personal Safety. You have the right to receive care in a safe setting and to be free from neglect, exploitation, and verbal, mental, physical, and sexual abuse, or harassment.” Tour of the ED was performed on 08/25/2025 from 10:35 AM - 11:07 AM by two surveyors accompanied by S1CNO, S3QM, and S4DED. Walking through the ED toward the psychiatric holding area, the surveyors noted the flow of traffic brought them through a corridor with four medical patient bays (13, 14, 15, 16) immediately before entering the area where the psychiatric patients were held. The two areas shared a wall, but there was no door to completely separate the two areas. Observation of the psychiatric holding area, also referred to by the staff as the patient overflow area, revealed five open patient bays on the left side of the room and a nursing station. Observation of the activity in the room revealed three psychiatric patients (spaced in every other bed), two ED techs in the room tending to the patients, one physician who was performing a patient exam, three security officers at the nurse’s desk checking patient belongings, and one registration staff member standing next to the nurse’s station, which was verified by S1CNO. In an interview on 08/25/2025 at 2:14 PM, S1CNO verified there was no door to the area and confirmed hospital staff will not block or fight with psychiatric patients to keep them at the hospital. S1CNO confirmed hospital staff will not physically engage with the patient. S1CNO confirmed hospital staff will not force the patient to stay at the hospital. Review of the ED census provided to the surveyors on arrival the morning of 08/26/2025 revealed two patients with a chief complaint of psychiatric evaluation. The patients were documented to be in exam rooms 18 and 21 in this unsecured area. S2QD verified on 08/26/2025 at 11:28 AM the psychiatric patients in rooms 18 and 21 were under a Physician’s Emergency Certificate (PEC). Repeat observations were performed on 08/27/2025 between 10:42 AM - 11:14 AM of the ED psychiatric holding area. During this observation it was verified by S2QD the five open patient bays in the unsecured area were also referred to as exam rooms 17, 18, 19, 20, and 21 on the ED census. In an interview on 08/28/2025 at 10:22 AM, S4DED confirmed the documented location of the patients on the ED census was always accurate and confirmed if it was documented in the census that patients were in rooms 17-21, the patients were in the psychiatric holding/ overflow area. This area had been previously confirmed to be without a door and staff would not force a patient to stay. 2.) The elopement of 2 (#1, #2) of 3 (#1, #2, #3) patients from the emergency department (ED) under a physician’s emergency certificate (PEC). Review of the hospital’s policy titled “Patient Elopement”, revised/reviewed 11/2024, revealed in part, “Policy: When any patient elopes or is believed to be missing, it is the policy of the Hospital to act in accordance with the welfare of the patient and the public while respecting the patient’s rights. Associates will take appropriate measures to facilitate the location and return of a patient who has eloped. A competent adult has the right to privacy, freedom of movement and association. A competent adult cannot be forced to return to the inpatient care unit unless admitted under EEC or PEC. When an incompetent patient is missing under any condition, the patient has ‘eloped’ and the patient may be detained and returned to the patient care unit to prevent the patient from harming him/herself or others.” Patient #1 Review of Patient #1’s ED visit dated 08/03/2025 revealed Patient #1 presented to the ED at 6:59 AM with a chief complaint of psychiatric evaluation. Review of the provider note revealed in part, “Medical Decision Making: Patient presents with acute psychosis. Patient with methamphetamine abuse reports that an incubus has been assaulting her since 2020. She reports it began after she met a man on the internet. She reports once she stopped the relationship she reports this incubus has been violating her. She reports that she cannot take it anymore. On my exam the patient is alert and oriented. She has normal work of breathing. Her lungs are clear to auscultation bilaterally. She has normal heart sounds with 2+ pulses in her radial arteries. There is no signs of external injury. She has bizarre thought content. Patient with acute psychosis. I will PEC this patient for being gravely disabled and unwilling to seek psychiatric care.” “Diagnosis: acute psychosis.” “ED Disposition: eloped.” Review of the PEC dated 08/03/2025 and signed at 7:32 AM revealed in part, Patient #1 was “gravely disabled and unwilling.” Review of the nurse’s note by S13RN revealed in part, 08/03/2025 8:22 AM: “Informed patient that she must move to back psych bed. Patient refused. Patient ripped out IV [intravenous] and began to walk out of hospital. Security intervened. Cops called.” Review of the hospital’s Security Report revealed in part, “On Sunday 08/03/2025, at approximately 7:05 AM Security Officers S7SO and S8SO responded to a call in ED holding for a new patient. Upon arrival Patient #1 refused to enter the BHU [behavioral health unit]. S9EDT and S10RN attempted to speak with her and was able to get her to sit in Ex [exam] 16, located just outside of BHU. S11MD then spoke with Patient #1 in Ex 16. Security was advised by medical staff that as of that time, Patient #1 was not under PEC orders and therefore did not need to be wanded. Security left the area.” “At approximately 8:11 AM Security responded to a call for a patient in Ex 14 (name not obtained). Medical staff informed Security that the patient had been uncooperative and while ripping the IV out of her arm, she almost stabbed S12RN. Therefore, she was being asked to leave by medical staff. Security then began notifying the patient in Ex 14 that she had to leave. At that time, Patient #1 in Ex 16 heard the conversation and told Security that if the patient in Ex 14 leaves, she is going to leave also. Through discussions, it was determined that the two were friends. When the patient in Ex 14 was leaving, Patient #1 also started to leave. I then asked S6RN if Patient #1 was under PEC orders. S6RN advised that she was, and I advised Patient #1 of such. I also advised her that [stated name] police department would be notified if she left. She then walked out the door headed east toward the park at approximately 8:23 AM. [Stated name] police department was notified by S6RN. A short time later, [stated name] police department were observed driving through the area. Patient #1 was not located, nor did she return. The patient from Ex 14 left shortly after Patient #1. No injuries nor threats were made during the incident.” In an interview on 08/25/2025 at 2:14 PM, S1CNO confirmed hospital staff will not block or fight with psychiatric patients to keep them at the hospital. S1CNO confirmed hospital staff will not physically engage with the patient. S1CNO confirmed hospital staff will not force the patient to stay at the hospital. S1CNO stated once a psychiatric patient under PEC walks out the door, hospital staff calls the police. S1CNO stated hospital staff will try to de-escalate the patient. S1CNO confirmed hospital staff reported Patient #1’s elopement to the police and Louisiana Department of Health (LDH). In an interview on 08/26/2025 at 2:49 PM, S11MD stated the triage nurse was concerned with Patient #1. S11MD stated he placed Patient #1 in room 16 next to the psychiatric area. S11MD stated he evaluated Patient #1 and PEC’d Patient #1. S11MD stated once he verbally alerted the staff that Patient #1 was under a PEC, the staff started wanding Patient #1 and that is when she escaped. S11MD stated the charge nurse notified the police before Patient #1 left. S11MD stated psychiatric patients are not left alone. S11MD stated he explained to Patient #1 that she was safe here. S11MD stated everyone is escorted to their room by staff. S11MD stated Patient #1 was extremely paranoid when she came in. S11MD stated he sat down with Patient #1 and he calmed Patient #1 down. S11MD stated he thinks Patient #1 decided to leave the ED when the staff started to wand her. S11MD stated the nursing staff talks to the patient. S11MD stated if a patient is escalated and clinicians are involved at that point the clinicians make assessments to see if the patient needs medication to calm down so they are no longer a threat to staff. S11MD stated if a PEC’d patient wants to leave the ED, we will restrain the patient. S11MD stated he wrote the order for medications and they were administered but did not calm Patient #1 down. S11MD stated his thought was he’s here to help her and give her Benadryl to calm her down and then move her to the back. S11MD stated Patient #1 did calm down after the medication was given. S11MD stated he ordered Geodon and Versed for Patient #1 as well. In a phone interview on 08/28/2025 at 9:52 AM, S13RN stated the physician evaluated Patient #1 and Patient #1 was placed under PEC. S13RN stated when staff went to move Patient #1 to the psych holding area that was when Patient #1 said she wanted to leave and started to rip her IV out. S13RN stated she told Patient #1 not to take her IV out and that she was going to get some gauze. S13RN stated when she got to the nurse’s station, she called security and that’s when Patient #1 ripped out her IV and started walking down the hall. S13RN stated security intervened. S13RN stated once security intervened she stayed at the nurse’s station. In a phone interview on 08/28/2025 at 10:11 AM, S8SO stated basically she was standing in the hallway watching the patient in Exam 14. S8SO confirmed she did not write the security report but everything in the report was correct. S8SO stated she was in the hallway when Patient #1 was walked out. Patient #2 Review of Patient #2’s ED visit dated 07/22/2025 revealed Patient #2 presented at 8:11 PM with a chief complaint of psychiatric evaluation. Review of the provider note revealed in part, “[stated age] white female with past medical history of schizophrenia and substance abuse presents to the emergency room via EMS [emergency medical services] after she was found on the road screaming about her sister being raped and 20 [sic] to a business that her family was not in. EMS reports the patient has been hypersexual and grabbing people scratches from sexual favors.” “Management: physical exam benign, psych social services consulted, patient PEC’d due to concerns for being a danger to themselves or others or being gravely disabled, labs ordered and collected; reviewed as above for medical clearance for psychiatric placement, medically stable.” “ED Course: 07/23/2025 10:32 AM Patient has become very agitated and is demanding to leave. Patient reports she does not need to be here and that she needs to go help her sister. I personally saw this patient and tried to talk her down. I explained why she is being held here for psychiatric evaluation. I explained to her that she is PEC. Security with the patient. Patient not agreeable and will not be talked down. Patient walked out of the emergency department. Police department notified. I ordered Haldol, Ativan, and Benadryl for her safety and ours.” “Diagnosis: acute psychosis.” Review of the PEC dated 07/22/2025 and signed at 8:18 PM revealed in part, Patient #2 was “gravely disabled and unable to seek voluntary admission.” Review of the nurse’s note by S14RN revealed in part, 07/23/2025 10:37 AM: “Multiple attempts to redirect patient without success. Patient resistant to stay and security involved. [Stated name] police department notified that patient left while under PEC.” Review of the hospital’s Security Report revealed in part, “On Wednesday, 07/23/2025 at approximately 10:28 AM a Security Alert was called in the ED holding area. I, S15SO and S16SO responded. Upon arrival, Patient #2 (who was under PEC orders) had left her bed (17) and was attempting to leave the ED holding area. I stepped in front of her to try to convince her to stay. She stated that she needed to get out of the ED because her sister will ‘continue to be raped’ if she stayed in the hospital. She was insistent upon leaving and said ‘please don’t touch me’. I told her I wasn’t going to and that I was not going to fight her to keep her here, but it was in her best interest to stay and get the help she needs. I explained to her that we would open the doors for her to leave but if we did and she left, we would have to call [stated name] police department. She said to call them. I opened the ambulance bay door and she walked out headed west down [stated name] Drive directly in front of the hospital. At that time [stated name] police department was called by ED personnel. I followed her until she crossed the street and headed south down [stated name] Drive. No threats nor injuries were made during the incident.” In an interview on 08/25/2025 at 3:31 PM, S1CNO confirmed Patient #2 was under PEC and was able to elope from the ED. She stated the hospital’s process is to call police and have the police return the patient to the hospital. In an interview on 08/26/2025 at 2:49 PM, S11MD stated Patient #2 was fixated on being the only one that could save her sister and we were keeping her here. S11MD stated Patient #2 was very delusional. S11MD stated he recalled talking to Patient #2 to redirect and calm her down. S11MD stated there were many staff members trying to redirect Patient #2. S11MD stated Patient #2 was very loud. S11MD stated Patient #2 was screaming and yelling and surrounded by security guards. S11MD stated she was escorted out. S11MD stated security guards were following her making sure she was not hurting anyone else and saw Patient #2 out the ED. S11MD stated staff were talking to the police explaining where Patient #2 was going. S11MD stated no nurse or other patient was hurt. S11MD stated they changed the way they do business in the ED. S11MD stated nurses were getting into fights resulting in injuries trying to keep this type of patients. In an interview on 08/28/2025 at 9:03 AM, S14RN stated Patient #2 was sleeping and when she woke up she walked out of the psych holding area. S14RN stated Patient #2 was down the hallway when he approached Patient #2. S14RN stated Patient #2 told him she was leaving. S14RN stated security was called. S14RN stated he explained to Patient #2 that she was PEC’d. S14RN stated Patient #2 still wanted to leave. S14RN stated he was able to de-escalate Patient #2 by talking with her and Patient #2 walked with him back to the psych holding area. S14RN stated there was a sitter in the psych holding area prior to Patient #2 walking out of that area. S14RN stated once he and Patient #2 were back in the holding area, security was present. S14RN stated Patient #2 then escalated again. S14RN stated Patient #2 wanted to leave the hospital. S14RN stated S11MD spoke to Patient #2 and tried to de-escalate Patient #2. S14RN stated Patient #2 insisted in leaving and ran down the hallway. S14RN stated he contacted the police department as soon as he found out that Patient #2 left the hospital. In an interview on 08/28/2025 at 9:20 AM, S15SO stated a security alert was called to the ED holding area. S15SO stated Patient #2 was PEC’d. S15SO stated when he approached Patient #2, she wanted to leave but she was not violent. S15SO stated Patient #2 told him not to touch her and he told Patient #2 he would not touch her. S15SO stated Patient #2 started walking down the hallway. S15SO stated he walked with Patient #2 down the hallway to the door. S15SO stated Patient #2 was very emotional but non-violent. S15SO stated he told Patient #2 if she walked out that they were going to call the police. S15SO stated Patient #2 wanted to use the phone. S15SO stated he told her no if you want to leave then you need to leave. S15SO stated he explained to her that they wanted her to stay at the hospital but Patient #2 still wanted to leave. S15SO stated he knew Patient #2 was under PEC orders. S15SO stated when security is called, they asked if the patient is under PEC orders or not. S15SO confirmed he opened the door to let Patient #2 walk out. 3.) Failing to ensure security officers had current de-escalation training for 1 (S16SO) of 4 (S7SO, S8SO, S15SO, S16SO) personnel records reviewed who responded to the elopements of Patient #1 and Patient #2. In an interview on 08/27/2025 at 2:39 PM S17HRD confirmed S16SO completed de-escalation training on 08/02/2023. S17HRD confirmed S16SO’s personnel record did not include documentation of de-escalation training for 2024 or 2025 (as of this survey). S17HRD confirmed all other staff are required de-escalation training on an annual basis. S17HRD stated she assumed security officers are required de-escalation training on an annual basis as well.”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital’s Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement. This deficient practice was evidenced by failing to identify opportunities for improvement related to 2 identified patient (#1, #2) elopements who were placed under a physician’s emergency certificate (PEC) in the emergency department (ED). Findings: Patient #1 Review of the Louisiana Department of Health (LDH) Hospital / Licensed Provider Abuse / Neglect Final Report revealed in part, date of incident: 08/03/2025. “At approximately 8:11 AM Security responded to a call for a patient in Exam Room 14 (name not obtained). Medical staff informed Security that the patient had been uncooperative and while ripping the IV [intravenous] out of her arm, she almost stabbed an associate. Therefore, she was being asked to leave by medical staff. Security then began notifying the patient in Exam 14 that she had to leave. At that time, Patient #1 in Exam 16 heard the conversation and told Security that if the patient in Exam 14 leaves, she is going to leave also. Through discussions, it was determined that the two were friends. When the patient in Exam 14 was leaving, Patient #1 also started to leave. I then asked S6RN if Patient #1 was under PEC orders. S6RN advised that she was, and I advised Patient #1 of such. I also advised her that [stated name] police department would be notified if she left. She then walked out the door headed east toward the park at approximately 8:23 AM. [Stated name] police department was notified by S6RN. A short time later, [stated name] police department were observed driving through the area. Patient #1 was not located.” Further review of the document revealed “initial actions taken: security and police were called.” Further review of the document revealed investigation results: unsubstantiated. In an interview on 08/25/2025 at 2:14 PM S1CNO confirmed hospital staff reported Patient #1’s elopement to the police and LDH. Patient #2 Review of the LDH Hospital / Licensed Provider Abuse / Neglect Final Report revealed in part, date of incident: 07/23/2025. “Multiple attempts were made to redirect Patient #2 without success. Patient #2 was resistant to stay and security was alerted. Security confronted Patient #2 at the door and attempts to de-escalate and get her to stay. Patient #2 continues down the hallway and out of the ambulance bay door. The [stated name] police department was notified by the charge nurse. Patient #2 exited the ambulance bay and headed south. The [stated name] police department were unable to located Patient #2.” Further review of the document revealed “initial actions taken: security was alerted to Patient #2 refusing to stay. After Patient #2 walked out, the [stated name] police department was called.” Further review of the document revealed investigation results: unsubstantiated. In an interview on 08/25/2025 at 3:31 PM S1CNO confirmed Patient #2 was under PEC and was able to elope from the ED. S1CNO confirmed the hospital’s process is to call police and have the police return the patient to the hospital. S1CNO confirmed there were no additional measures initiated to prevent further elopements.”

“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 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 general surgery services for 1 (#19) of 22 (#1-#22) sampled patients (see findings tag A-2411).”

“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 general surgery services for 1 (#19) of 22 (#1-#22) sampled patients. Findings: Review of the hospital’s policy titled “EMTALA - Transfer” revised/reviewed date 12/24, revealed in part, “11. Specialized Facilities. 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) may not refuse to accept from a referring hospital within the boundaries of 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.” Review of the hospital’s transfer center’s transfer order dated 12/26/2024 revealed in part, the referring hospital, hospital ‘B’ was requesting transfer of Patient #19 for higher level of care for surgery services with a bed type of medical/surgical. Further review of the document revealed on 12/26/2024 at 10:58 p.m., contacted S4MD, explained patient condition and transfer request, declined stating that this patient needs to go back to his original surgeon. Review of Patient #19’s emergency department record from hospital ‘B’ revealed in part, Patient #19 arrived on 12/26/2024 at 4:03 p.m. Review of the nurse’s notes revealed in part, Presenting complaint: Patient states: patient had hernia surgery 3 weeks ago in Houston. Patient states surgical incision started bleeding on Sunday. Patient called surgeon’s office and they told him to just “leave it uncovered during the day.” Today patient’s incision is draining and patient states that his abdomen is “hard and hot.” Transition of care: patient was not received from another setting of care. Review of the physician documentation revealed a diagnosis of disruption of external operation (surgical) wound, not elsewhere classified. Review of the Patient Transfer Out Form revealed in part, criteria/reason for transfer: for equipment or services not available at this facility: General Surgery with a diagnosis of wound recheck, rule out intra-abdominal abscess. Further review of the document revealed Patient #19 was accepted to hospital ‘C’ on 12/26/2024. Review of the hospital’s physician on-call schedule revealed in part, S4MD was on call for general surgery on 12/26/2024. In a phone interview on 01/15/2025 at 1:53 p.m., S4MD stated the best place for Patient #19 was to go back to the original surgeon. S4MD stated that is very appropriate to send the patient back to the original surgeon. S4MD stated Patient #19 had surgery approximately 2 weeks prior and the original surgeon should see the patient. S4MD stated that’s the surgeon’s patient. S4MD stated as a surgeon, if that was my patient and I had operated on the patient, then that is my patient. S4MD stated if Patient #19 was unstable then he would have accepted Patient #19. S4MD stated that was not the case with Patient #19 because Patient #19 was stable. S4MD verified he was the general surgeon on call on 12/26/2024. S4MD verified Patient #19 was declined transfer due to needing to go back to the original surgeon. In an interview on 01/16/2025 at 1:16 p.m. S2CNO verified there was a bed available in the medical/surgical units on 12/26/2024. Review of Patient #19’s emergency department record from hospital ‘C’ revealed in part, Patient #19 arrived on 12/27/2024 at 10:51 a.m. Review of the emergency department provider note revealed in part, In brief, 56-year-old male with past medical history of hypertension, hyperlipidemia, small intestine rupture, inguinal and ventral hernia status post multiple repairs presents emergency department as a transfer from outside hospital for evaluation by general surgery after being found to have a large fluid collection within his superficial abdominal wall and intra-abdominal fluid collection. Initially noticed drainage on Sunday that has progressively worsened. Plan: given unknown etiology of patient’s fluid collection he was covered broadly in the event that this is an infection. On repeat lab work patient’s left shift appears to have improved with neutrophil count of 7.10. Patient was consulted to general surgery who evaluated him at bedside and performed a drainage of his large fluid collection with thus far 700 milliliters of blood output. Clinical Impressions: Abscess of postoperative wound of abdominal wall, Infected hernioplasty mesh, and Abdominal fluid collection. On 12/27/2024 at 5:24 p.m. Patient #19 was admitted to trauma surgery.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This deficient practice was evidenced by failing to ensure emergency department nursing staff were qualified as per their job description for 2 (S2CD, S5RN) of 5 (S2CD, S3RN, S4RN, S5RN, S6RN) RN personnel records reviewed. Findings: Review of the job description for registered nurse revealed in part, C. Licenses, Registrations, or Certifications: BLS within 2 weeks of hire. Review of the Addendum for Emergency Department RN attached to the job description revealed in part, please list or describe any additional duties and responsibilities that you perform in your specific position that are not otherwise reflected on this job description. 1.) Current PALS certification at time of hire or within 12 weeks of hire for experienced RNs or completion by the end of the clinical orientation period for new graduate nurses. Maintain certification thereafter. 2.) Current ACLS certification at time of hire or within 12 weeks of hire for experienced RNs or completion by the end of the clinical orientation period for new graduate nurses. Maintain certification thereafter. 3.) Current TNCC and ENPC certification within 12 months of hire for experienced RNs or completion within 18 months of hire for new graduate nurses. Maintain certification thereafter. Review of S2CD’s personnel record revealed a hire date of 09/06/2004. Further review failed to reveal current BLS, ACLS, PALS, or TNCC certifications. In an interview on 09/19/2024 at 2:30 p.m. S2CD stated he sometimes works as a RN in the emergency department. S2CD verified he does not have current BLS, ACLS, PALS, or TNCC certifications. S1CNO stated S2CD’s job description only requires him to have current BLS due to him being the ED Clinical Director. When asked if all RNs that work in the emergency department are required to have current BLS, ACLS, PALS, and TNCC certifications, S1CNO stated yes. When asked if S2CD is working in the emergency department as a RN should he be required to have the above stated certifications as do all other RNs working in the emergency department, S1CNO stated well when presented like that, then yes. Review of S5RN’s personnel record revealed a hire date of 09/16/2019. Further review failed to reveal a current TNCC certification. In an interview on 09/19/2024 at 3:12 p.m. S2CD verified there was no documentation of current TNCC certification in S5RN’s personnel record.”